Self-Designation of the Treated Eye Before Intravitreal Injections

Haim, Liron Naftali Ben; Rozenberg, Eldad; Shapira, Yinon; Beiran, Itzchak; Zayit‐Soudry, Shiri

doi:10.1097/iae.0000000000002956

Cited by 2 publications

(1 citation statement)

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“…After consent, the process of site marking may be error prone. A recent study demonstrated that a percentage of patients cannot name the eye to be injected . Finally, the common scenario of a surgeon leaving the examination room to attend to a different patient and then reentering later to perform the injection can be a source of subsequent error.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of a Series of Wrong Intravitreous Injections

et al. 2021

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n 1999, the Institute of Medicine published a landmark report that highlighted the impact of medical errors. 1 Within ophthalmology, surgical confusions are quite rare, with placement of a wrong intraocular lens the largest reported risk. [2][3][4][5] Despite intravitreous injections being performed in greater numbers than cataract surgery, 6 errors in injections appear to have limited coverage in the literature. 2,3,7,8 Although it has been hypothesized that such errors are underreported because they do not result in substantial harm, 3 a leading ophthalmic insurance carrier has noted an increase in malpractice activity due to wrong events in retina. 9,10 In this report, we describe a series of errors involving intravitreous injections that were performed within Kaiser Permanente Northern California (KPNC). MethodsWithin KPNC, 37 fellowship-trained retina specialists care for approximately 4.5 million members and collectively performed more than 78 000 intravitreous injections in 2019 and 68 000 in 2020.Formal investigations of any untoward event may be prompted by physicians, patients, or staff. These reviews are legally protected and led by departmental chairs. Furthermore, specialties perform their own informal quality improvement and patient safety projects. It is from these sources that the authors were able to identify cases of errors in intravitreous injections described herein, occurring between January 1, 2019, and December 31, 2020. These cases were the only errors in retina events identified during the 2-year period.This study was reviewed by the KPNC Institutional Review Board and considered exempt, not meeting criteria for human research. Informed consent was not required by the IRB as the study did not involve any of 18 protected health information identifiers. This retrospective study adhered to the Declaration of Helsinki. Results Case 1: Wrong EyeA patient who was undergoing treatment for neovascular agerelated macular degeneration in both eyes with the same anti-IMPORTANCE This case series describes events associated with errors in intravitreous injections. Given the volume of injections performed worldwide, it is important to identify the factors associated with these wrong events to try to reduce their occurrences.OBJECTIVE To evaluate a series of errors in intravitreous injections within Kaiser Permanente Northern California (KPNC). DESIGN, SETTING, AND PARTICIPANTSIn this retrospective small case series of a convenience sample at KPNC between January 1, 2019, and December 30, 2020, cases of errors in intravitreous injection were identified either as part of a formal institutional quality review or by self-report of the involved surgeon during quality improvement discussions.MAIN OUTCOMES AND MEASURES Description of the medical errors and the circumstances surrounding these errors. RESULTSDuring the 2 years of this evaluation, there were more than 147 000 injections performed within KPNC. Four cases of errors in intravitreous injection were identified. Mistakes were associated with inaccurat...

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Section: Discussionmentioning

confidence: 99%