Journal article

Intraocular Lens Confusions: A Preventable " Never Event" -The Royal Victorian Eye and Ear Hospital Protocol

E Zamir, K Beresova-Creese, L Miln

Survey of Ophthalmology | ELSEVIER SCIENCE INC | Published : 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. © 2012 Elsevier Inc..

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University of Melbourne Researchers

Grants

Awarded by National Health and Medical Research Council


Funding Acknowledgements

The authors report no proprietaiy or commercial interest in any product mentioned or concept discussed in this article. Centre for Eye Research Australia receives operational infrastructure support from the Victorian Government. Publication of this article was supported by the National Health and Medical Research Council Centre for Clinical Research Excellence #529923 - Translational Clinical Research in Major Eye Diseases.