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Error prone: 21 NHS patients receive an incorrect intraocular lens

Recommendations for improving IOL safety have been released by the Healthcare Safety Investigation Branch

06 Dec 2018 by Selina Powell

A report aimed at reducing the number of incorrect intraocular lens (IOL) implantations has been published by the Healthcare Safety Investigation Branch (HSIB).

The document revealed that mistaken IOL implantation is one of the most commonly reported ‘Never Events’ within the NHS.

Never Events are defined as “serious incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.”

In 2017, there were 21 instances of patients receiving the wrong IOL. This compares with 20 patients who received the wrong knee prosthesis and five patients who had an incorrect hip implant.

The HSIB recommended that the Department of Health and Social Care commissions technology for the NHS that would provide digital alerts when incorrect IOLs are selected.

It also suggested that the Royal College of Ophthalmologists set up an expert working group to ensure consistent IOL practice – for example, around the use of checking processes, technology and compliance with existing guidance.

HSIB stated that the Medicines and Health products Regulatory Agency should encourage manufacturers of ophthalmology electronic patient record systems to comply with human factors engineering and usability guidance. 


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  • Avatar image of person name

    Interesting to see what is the definition of an incorrect intraocular lens is.
    I suspect if all patients had a post evaluation form, that many more patients than 21 would report they have an incorrect lens/refractive outcome.
    Not all patients wish to be corrected for infinity. Especially the older patient who doesn’t go out often, being left slightly myopic appears to be a better solution for every day life. If the biometry calculation is for a slight myopic correction, that reduces a “refractive surprise” that causes a functional problem. If you aim for -1.00 but are out by 1 then the result is Plano or -2.00 both more acceptable than +1.00. Possibly some form of monovision is better, say dominant RE -1.00 LE -2.00, easy to see the clock, medicines, cup of tea, the floor, etc. When we are elderly and forget spectacles being left slightly myopic we can see well in our world.
    Biometry surprises with the IOL Master appear to be rare unless you enter the incorrect information or use the wrong lens constant. Dense cataract though rarer these days is harder to manage. Ultrasound if needed, means a guesstimate on the velocity linked to the density of the cataract . But as eyes are often similar using the Axial length of the other eye is often useful for the calculation.

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