Eyeworld

113 EW INTERNATIONAL September 2016 3. Neily J, et al. Examining wrong eye implant adverse events in the Veterans Health Administration with a focus on prevention: A preliminary report. J Patient Saf. 2015 Mar 16. [Epub ahead of print] Healthcare System, Vanderbilt Eye Institute, Nashville, and Julia Neily, RN, Veterans Health Administration, National Center for Patient Safety, Field Office, White River Junction, Vermont. "We also reported expired lens implants as adverse events." Pearls to avoid IOL mistakes Working as a surgical team can go a long way toward avoiding IOL errors, Dr. Chomsky and Ms. Neily said. "Once the appropriate lens style and power is decided on by physician and patient, the verifi- cation process and prevention of wrong implants is a team approach." Dr. Steeples suggested immersive simulation training that involves the whole surgical team to help improve team performance and communi- cation to develop robust systems to detect and prevent mistakes. Here are some of the pearls suggested in the study to avoid IOL mistakes: 1. Provide consistent checks, with a three-stage approach that involves: a) identity and document check; b) right or left eye check; and c) IOL check repeated at each stage. 2. Refer to source biometry and clin- ical documents during IOL checks at each stage listed above. Any unusual powers or models or negative powers can be confirmed during the "team brief" and "time-out" stages; always check the selection is made using the correct formula, A-constant, and pertains to the correct eye. 3. To avoid transcription errors, do not write out multiple IOL selections onto white boards or lists. Match the transcription to a single patient and his or her identifying data. Note any minus lens powers with the word minus. If transcriptions are used, they should only be on locally agreed IOL selection sheets. Use clear handwriting. EW References 1. Steeples LR, et al. Wrong intraocular lens events—what lessons have we learned? A review of incidents reported to the National Reporting and Learning System: 2010–2014 versus 2003–2010. Eye. 2016;30:1049–55. 2. Kelly SP, et al. Wrong intraocular lens implant; learning from reported patient safety incidents. Eye. 2011;25:730–734. Editors' note: The sources have no financial interests related to their comments. Contact information Chomsky: Amy.Chomsky@va.gov Neily: Julia.Neily@va.gov Steeples: Laura.Steeples@cmft.nhs.uk > Tall lens body ideal for deep set eyes > Superior clarity & depth of focus > Wider flange contact stays on eye > Nimble size great for use on small eyes Find out more at volk.com [ Superior Focusing Ability ] Idrees & Singh MidVitreous Lenses Best Laser Vitreolysis Lenses on the Market 1 Photo courtesy Karl Brasse, MD c.2015

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