Bosses at a hospital in Leicester have apologised and launched an investigation after surgeons put the wrong size lens in a patient’s eye.
The incident – classed as a “never event” – meant the patient had to be taken back into theatre at Leicester Royal Infirmary to have the lens removed and replaced with one which was the right size.
“Never events” are serious, preventable incidents that the Government says should never happen. The hospital has seen two of these types of events in the space of 18 months, with a patient in 2012 also having an incorrect lens fitted.
Amanda Randle, senior patient safety manager at Leicester’s hospitals, said: “In September, we reported a ‘never event’ within ophthalmology following the implantation of the wrong size lens.
“The error was identified by the surgeon, who immediately apologised to the patient and took them straight back into theatre to replace the incorrect lens.
“The incident has been correctly reported and is being investigated.
“Unfortunately, this never event was due to human error. The surgeon misread the lens size from the
operating list, which caused no long-term damage to the patient. We are very sorry for any distress.”
Ms Randle said following a similar incident in April 2012, an “intra-ocular lens protocol” was developed for staff working within ophthalmic theatres. This states that it is the surgeon’s responsibility to select and place the lens within theatre, with an additional procedure in place to pause and double check the lens before it is implanted. This procedure is recorded on the database at the hospital and compliance checked.
A spokesman for this latest incident said in this instance the surgeon believed that the correct lens had been chosen after misreading the operation list.
The lens detail was then transcribed on to a white board and this meant that a “stop” moment – where the details are double checked – did not pick up on any selection error.
“The investigation will consider what further actions may be needed to prevent this type of error happening again,” the spokesman said.
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