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
“time-out” processes being followed prior to the regional block or procedure.
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
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.
prior to incision, the surgeon
verifies the operative eye with the ophthalmic
history and exam.
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
AAEEH, March 2001.
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
- If at all possible, there should only be one IOL measurement per eye on the form.
If your computerized
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
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.
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
more information on the Patient Safety Registry,
adverse health event reporting or this alert, contact Julie Apold, MHA patient safety registry manager, at firstname.lastname@example.org or (651) 641-1121 or toll-free
at (800) 462-5393.
These are suggested
for a checklist;
however, they may not be appropriate,
feasible or desirable in all settings and
all patients. This checklist
not be deemed inclusive of all
to verify the operative eye, or exclusive of other
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
circumstances presented by
patient, setting of care,
These are suggested ideas for verification
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
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
patient, setting of care,