Researchers at Kaiser Permanente Northern California recently reviewed and reported medical errors involving intravitreal injections performed from January 1, 2019 to December 31, 2020 (JAMA Ophthalmol 2021;139(10):1123-1125). They identified four cases where either the wrong eye (2 cases) or wrong medication / dosage (2 cases) were injected.
The study authors noted that, in each instance, the surgical team had not adequately followed a pre-procedural checklist designed to prevent such errors.
Fortunately, none of the four cases resulted in any long-term harm to the patients. The relatively low incidence (0.002%) of the errors identified and lack of harm associated do not erase the need for vigilance in preventing wrong-site treatments.
At Ticho Eye Associates, while no cases of harm to patients from wrong-site surgery have ever been identified in over 30,000 procedures, we continue to conduct the appropriate “time out” protocols to prevent such occurrences.
Benjamin H. Ticho, MD