Symbol Error – Risk Alert

1. Connie HY Lai¹
2. YL Wong²
3. Angelina MH Tong²
4. Christina YS Tsang²
5. YY Lee¹
6. Philip TH Lam²

¹Alice Ho Miu Ling Nethersole Hospital, Hong Kong
²Prince of Wales Hospital, Hong Kong

Purpose : Refractive surprise is occasionally encountered after successful Cataract surgery, which results in liability claims. Surgeons are ultimately responsible if wrong IOL is implanted. A sentinel event happened in HK: wrong IOL implantation. A new IOL checking protocol coupled with an audit is then developed to evaluate the effectiveness of the new system so as to avoid recurrence of similar event due to system failure.

Methods : An audit of 413 cataract cases was done subsequently in different operating theatre. The audit aims to evaluate the effectiveness of the new IOL checking and meanwhile to increase staff awareness on IOL checking.

Results : No incidents of wrong IOL were reported with 100% compliance of each audited items.

Conclusions : New IOL checking system is proven to be effective to avoid wrong IOL implantation. The new strategies include unification of IOL checking procedures in all OT settings, use standardized IOL prescription form and modification of 'look-alike' IOL package specifically for 'plus' & 'minus' lens coupled with integration of 'Time Out' strategy. With these strategies, team effort for preventing wrong IOL implantation can be achieved.