Background

MHA and MDH have reviewed data from the adverse health event reporting system and have noted a cluster of invasive eye procedures that have resulted in either the procedure being performed on the wrong eye or the wrong lens being inserted into the eye. Facilities have found that these events have occurred primarily due to inconsistent or ineffective processes for marking the correct eye and/or non-existent or ineffective verification/ “time-out” processes being followed prior to the regional block or procedure.

Recommendation

MHA and MDH recommend that facilities implement the Safest in America/Institute for Clinical Systems Improvement Safe Site Protocol for Invasive and Surgical Procedures that was updated in January, 2006 (see PDF) for invasive eye procedures. A Joint Statement of the American Academy of Ophthalmology (AAO), the American Society of Ophthalmic Registered Nurses (ASORN) and the American Association of Eye and Ear Hospitals (AAEEH) provides additional specific suggestions for verifying the operative eye and minimizing wrong incorrect intraocular lens (IOL) placement.

Suggestions for a Checklist to Verify the Operative Eye

*Developed by the AAO Quality of Care Secretariat in collaboration with ASORN and AAEEH, March 2001

• The patient’s informed consent form describes the operative eye (e.g., right eye, left eye, abbreviations are not acceptable), and the patient understands which eye is being operated on and which procedure is being performed.
• The ophthalmic history and exam are available in the operating room.
• Prior to administration of eye drops or medication, the nurse asks the patient which eye is being operated on. 
• The patient’s response, the informed consent, the doctor’s orders for medication or dilation of the operative eye, and the ophthalmic history and exam all match for operative eye.
• The surgeon/assistant surgeon marks the skin next to the operative eye with his/her initials. 
• Prior to administration of anesthetic injection or sedation, the anesthesia staff /surgeon verify the operative eye with the patient, informed consent and/or the ophthalmic history and exam, and they all match.
• Immediately prior to incision, the surgeon verifies the operative eye with the ophthalmic history and exam.
• If there is any discrepancy among the patient’s response, the informed consent, the doctor’s orders, ophthalmic history and exam, the surgeon makes the final determination and the discrepancy is corrected before proceeding with the procedure.

Suggested Multiple IOL Verification Procedure in the Operating Room for Minimizing Wrong IOL Placement

**Developed by the AAO Quality of Care Secretariat in collaboration with ASORN and AAEEH, March 2001.

• The ophthalmic history and exam and form that contains keratometry and axial length, primary and alternate lens/es for each patient are available in the operating room. •     
• If at all possible, there should only be one IOL measurement per eye on the form. If your computerized IOL measurement program allows, refrain from printing measurements for the left and right eyes on one form.
• The surgeon/ assistant surgeon selects the primary and alternate IOL/s before the start of the case. The surgeon verifies the IOL number, diopter, optic, A constant, and length against the IOL Calculation Report form or documentation and/or patient medical record.
• Before incision or when the surgeon requests the IOL, the circulating nurse shows the IOL box to the surgeon. The surgeon and circulating R.N. verify the IOL model, power and other calculation information, patient identification, and operative eye against the IOL Calculation Report.
• The circulating nurse then repeats this procedure with the scrub nurse/technician (i.e. shows the IOL box and verbally states the model number and lens power). •     
• The scrub nurse/technician verbally states the model number and lens power as he/she passes the lens to the surgeon for implantation.
• The surgeon may elect to perform visual inspection of the IOL under the microscope for appropriateness and any lens defect or deposit.
• If there is a discrepancy, the surgeon reviews the IOL Calculation Report or ophthalmic history and exam and /or designated institute form.
• The circulating nurse puts the IOL labels on the IOL card, operative record/patient chart right after the surgeon implants the IOL. He/she documents the IOL verification procedure in the patient record.

For more information on the Patient Safety Registry, adverse health event reporting or this alert, contact Julie Apold, MHA patient safety registry manager, at japold@mnhospitals.org or (651) 641-1121 or toll-free at (800) 462-5393.

*AAO DISCLAIMER: 

These are suggested ideas for a checklist; however, they may not be appropriate, feasible or desirable in all settings and for all patients. This checklist should not be deemed inclusive of all proper methods to verify the operative eye, or exclusive of other protocols that are reasonable at obtaining the same results. The ultimate judgment regarding the utility and application of suggestions listed herein must be made by the operating surgeon (in collaboration with nursing and anesthesia staff) in light of all the circumstances presented by the patient, setting of care, and other factors.

**AAO DISCLAIMER:

These are suggested ideas for verification procedure. However, they may not be appropriate, feasible or desirable in all settings and for all patients. This verification procedure should not be deemed inclusive of all proper methods to verify the appropriate IOL, or exclusive of other protocols that are reasonable at obtaining the same results. The ultimate judgment regarding the utility and application of suggestions listed herein must be made by the operating surgeon (in collaboration with nursing staff) in light of all the circumstances presented by the patient, setting of care, and other factors.