Examining Wrong Eye Implant Adverse Events in the Veterans Health Administration With a Focus on Prevention: A Preliminary Report

Journal of Patient Safety
Julia NeilyWilliam Gunnar

Abstract

The study goals were to examine wrong intraocular lens (IOL) implant adverse events in the Veterans Health Administration (VHA), identify root causes and contributing factors, and describe system changes that have been implemented to address this challenge. This study represents collaboration between the VHA's National Center for Patient Safety (NCPS) and the National Surgery Office (NSO). This report includes 45 wrong IOL implant surgery adverse events reported to established VHA NCPS and NSO databases between July 1, 2006, and June 31, 2014. There are approximately 50,000 eye implant procedures performed each year in the VHA. Wrong IOL implant surgery adverse events are reported by VHA facilities to the NCPS and the NSO. Two authors (A.C. and J.N.) coded the reports for event type (wrong lens or expired lens) and identified the primary contributing factor (coefficient κ = 0.837). A descriptive analysis was conducted, which included the reported yearly event rate. The main outcome measure was the reported wrong IOL implant surgery adverse events. There were 45 reported wrong IOL implant surgery adverse events. Between 2011 and June 30, 2014, there was a significant downward trend (P = 0.02, R = 99.7%) at a pace of -0.08 (per 1...Continue Reading

References

Nov 25, 2006·Ophthalmology·George J C JinJason J Jones
Nov 14, 2007·Archives of Ophthalmology·John W SimonDavid Strogatz
Jun 3, 2009·Ophthalmology·Flora Lum, Andrew P Schachat
Nov 18, 2009·Archives of Surgery·Julia NeilyJames P Bagian
Mar 10, 2010·Quality & Safety in Health Care·Brigid M GillespieClare Fenwick
Mar 20, 2010·Patient Safety in Surgery·George G Youngson, Rhona Flin
Mar 23, 2010·The Surgeon : Journal of the Royal Colleges of Surgeons of Edinburgh and Ireland·Tony O'ConnorI Keogh
Oct 21, 2010·JAMA : the Journal of the American Medical Association·Julia NeilyJames P Bagian
Jul 20, 2011·Archives of Surgery·Julia NeilyJames P Bagian
Jun 19, 2012·Ophthalmology·Oliver D ScheinAndrew P Schachat

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Citations

Jul 31, 2016·AORN Journal
Dec 29, 2020·Ophthalmology·Emily ColeUNKNOWN American Academy of Ophthalmology Medical Information Technology Committee

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