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New ways to avoid wrong IOLs    

13 December 2017

The Royal College of Ophthalmologists is aware that never events relating to the insertion of wrong intraocular lenses (IOLs) is an ongoing problem and that members continue to have concerns about how best to avoid such incidents, and about how to ensure there is no unhelpful blame or punitive measures which lead to financial penalties or inhibit reporting and learning.

The College has been actively responding to NHS England and NHS Improvement (NHSI) consultations on never events and is grateful to the many members who also submitted responses. Following the last consultation in 2016, members should be aware that commissioners can no longer impose financial sanctions on trusts when they report a never event and that the next version of the never event framework, due over the next 2-3 months, will be part of the serious incident framework rather than a standalone publication, to try to reduce any negative connotations to the term never event beyond that of any other serious incident.

In addition, Melanie Hingorani, RCOphth Chair Professional Standards has been liaising directly with the never events lead for NHSI and has agreed inclusion of a much clearer definition for never events for the new publication. The advice at this point, prior to the release of the new framework publication, is to ensure that a definite statement is made, usually at the WHO checklist sign in or time out, of the “surgical plan” for the IOL make and model, and that this is clearly recorded in the notes. It is only from that point on that a wrong IOL would be a never event. Any error prior to that, for instance where the wrong implant is due to incorrect preoperative biometry measurements or incorrect interpretation of the preoperative data (eg due to wrong person biometry or due to using wrong set of data from correct biometry) would be a serious incident but not a never event. This will be made totally explicit in the new never event publication and will be accompanied in the appendix by example case studies of wrong IOLs that are and are not never events. We will notify members when this is published.

In addition, Moorfields Eye Hospital had made an informal enquiry to the new Healthcare Safety Investigation Branch (HSIB) to consider investigating wrong IOLs as a national priority. The HSIB has now identified a recent wrong IOL never event which has been able to trigger this process and is now launching a full investigation into the insertion of an incorrect intraocular lens.  The investigation will consider how staff use and interact with specialist technology, as well as the processes behind decision making and procurement. Moorfields and the College will provide full support to this process including expert advice as required.

The HSIB is funded by the Department of Health and hosted by NHSI, but operates independently of them and other organisations such as the Care Quality Commission (CQC). They are a team of experienced safety investigators, led by the chief investigator Keith Conradi. The HSIB investigates up to 30 safety incidents each year in order to provide meaningful safety recommendations and share learning across the whole of the healthcare system for the benefit of everyone who is cared for by it and works in it. They take on areas which are a significant and ongoing national concern. They have a team of about 30 people with a range of expertise, with backgrounds in the NHS, aviation and military investigations, human factors specialists and other investigator expertise and aim to use this range to offer new insights into causes and potential solutions including technical solutions.  or contact