Inside Our Near-Miss Wrong-Site Surgery
Lessons learned from almost implanting the wrong IOL.
A
t a busy cataract
facility like ours, a
simple misstep is all
it takes to implant the wrong-
powered intraocular lens. But
we were confident that we'd
pick and verify the right IOL
for each and every one of the
5,000-plus cataract cases we
perform a year. We thought
our 3-level system of verifica-
tion and our time out prac-
tices were foolproof. We
thought wrong.
There was a crack in our
system just wide enough for a wrong-site surgery to fall through. Not
long ago, we ordered and pulled the wrong intraocular lens, and were
seconds away from inserting an AMO ZCT225 11.5D instead of an
AMO ZCT150 11.5D. Luckily, we caught the near-miss in the nick of
time, thanks in large part to the courage of a vigilant tech who spoke
up at the last second when she sensed something was wrong. Since
our near miss, we've shored up the crack in our system — and
learned some valuable lessons.
Here's what our verification system looks like. We confirm 3 times
that the lens model and power the surgeon ordered matches the lens
that we pick. This doesn't include the time out that we conduct in the
OR.
Our policy states that the surgeon should have the lens order in
3 4 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • D E C E M B E R 2 0 1 7
Safety
Kelly A. Fitzpatrick, RN, BSN, MBA
• RED ZONE A nurse wears a red bouffant
while picking and verifying lens implants in
the OR corridor at the Garden City (N.Y.)
SurgiCenter. The red bouffant lets staff and
surgeons know that they're not to interrupt
the nurse picking lenses for any reason.
Kelly
A.
Fitzpatrick,
RN,
BSN,
MBA
