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Intraocular lens confusions: a preventable "never event" - The Royal Victorian Eye and Ear Hospital protocol.

Authors :
Zamir E
Beresova-Creese K
Miln L
Source :
Survey of ophthalmology [Surv Ophthalmol] 2012 Sep; Vol. 57 (5), pp. 430-47.
Publication Year :
2012

Abstract

Intraocular lens (IOL) confusions and errors are among the most common postoperative adverse events. Errors may occur at any stage from the decision to operate to the insertion of the IOL. The most common errors occur during IOL selection pre-operative preparation (anaesthesia given before recognition that the intended IOL is not available), or intraoperatively (wrong IOL implanted because of confusion in the operating room). We review the mechanisms of errors reported in the literature and describe the experience at The Royal Victorian Eye and Ear Hospital. We also describe the implementation of an error-detection protocol and provide qualitative data on its performance.<br /> (Copyright © 2012 Elsevier Inc. All rights reserved.)

Details

Language :
English
ISSN :
1879-3304
Volume :
57
Issue :
5
Database :
MEDLINE
Journal :
Survey of ophthalmology
Publication Type :
Academic Journal
Accession number :
22898650
Full Text :
https://doi.org/10.1016/j.survophthal.2011.12.003