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. 2022 Apr 22:16:1255-1259.
doi: 10.2147/OPTH.S360628. eCollection 2022.

Reducing Injection-Related Safety Events in Retina Clinics

Denise A John  1 , Beth Hansemann  1 , Philip Lieu  1 , Jennifer Weizer  1
Affiliations

Reducing Injection-Related Safety Events in Retina Clinics

Denise A John et al. Clin Ophthalmol. .

Abstract

Purpose: At the Kellogg Eye Center, we identified a series of injection-related patient safety events that led to a systematic review and redesign of our intravitreal injection protocol. The objective was to reduce injection-related patient safety events to zero.

Methods: A retroactive review, using the Healthcare Failure Mode and Effect Analysis model as a guide, was performed on our process for delivering intravitreal injections to identify potential failure modes and their impact.

Results: The total number of injection-related safety events was 1 in 2017 and 16 in 2018 at baseline. Potential vulnerabilities identified included errors in communication, patient identification, clinical documentation, and medication orders. The injection protocol was redesigned. After implementation, there were zero injection-related safety events in all Kellogg Eye Center Retina clinics for the subsequent 18-month follow-up period.

Conclusion: It is possible to redesign and implement an intravitreal injection protocol to reduce the rate of safety events in a large academic eye center.

Keywords: adverse event; healthcare failure mode and effect analysis; intravitreal injections; patient safety.

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Conflict of interest statement

The authors report no conflicts of interest in this work.

Figures

Figure 1
Figure 1
Intravitreal injection process map.
Figure 2
Figure 2
Kellogg Eye Center pre-procedure time-out.
See this image and copyright information in PMC

References

    1. Haddock LJ, Ramsey DJ, Young LH. Complications of subspecialty ophthalmic care: endophthalmitis after intravitreal injections of anti-vascular endothelial growth factor medications. Semin Ophthalmol. 2014;29(5–6):263–275. doi:10.3109/08820538.2014.959616 - DOI - PubMed
    1. Grzybowski A, Told R, Sacu S, et al. Update on Intravitreal Injections: euretina Expert Consensus Recommendations. Ophthalmologica. 2018;(239):181–193. doi:10.1159/000486145 - DOI - PubMed
    1. Barash A, Lim JI, Tripathy K, et al. Intravitreal Injections. EyeWiki. 2020;1:34.
    1. Uhr JH, Xu D, Rahimy E, et al. Current Practice Preferences and Safety Protocols for Intravitreal Injection of Anti-Vascular Endothelial Growth Factor Agents. Ophthalmol Retina. 2019;3(8):649–655. doi:10.1016/j.oret.2019.03.013 - DOI - PubMed
    1. Kelly SP, Barua A. A Review of Safety Incidents in England and Wales For Vascular Endothelial Growth Factor Inhibitor Medications. Eye. 2011;25(6):710–716. doi:10.1038/eye.2011.89 - DOI - PMC - PubMed