Archive December 2017 XVIII, No. 12

Safety: Inside Our Near-Miss Wrong-Site Surgery

Lessons learned from almost implanting the wrong IOL.

Kelly Fitzpatrick

Kelly Fitzpatrick, RN, BSN, MBA


red bouffant 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.

At 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 verification and our time out practices 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 at least 5 days before surgery. About 10% of our docs don't meet this timeframe for various reasons. Maybe the patient didn't go in for her biometer testing yet so we don't have the IOL power calculation. Maybe the doc's on vacation.

We have to have 2 of the lenses that the surgeon orders in stock — 1 as the primary and the other as a backup in case we drop the primary on the OR floor. Once we get the lens order form, we pull the lens and wrap the form around the package. The nurse that picks the lens signs the form to confirm that the lens we ordered matches the lens that will be present in the OR for the case.

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