New Report Looks at Injection Errors in Ophthalmology


There were 4 errors found involving wrong medications or injections in the wrong eye at KPNC in 2019 and 2020.

Robin A. Vora, Kaiser Permanente Northern California

Robin A. Vora, MD

A new report shows errors in intravitreous injections for ophthalmology are rare and do not often lead to long-term damage at Kaiser Permanente Northern California (KPNC).

A team, led by Robin A. Vora, MD, Kaiser Permanente Northern California, evaluated a series of errors in intravitreous injections within Kaiser Permanente Northern California,

Errors in Medicine

According to a 1999 report issued by the Institute of Medicine, surgical confusions are very rare within ophthalmology, with the largest reported risk being placement of a wrong intraocular lens.

However, previous reports have been limited on errors in intravitreous injections despite being performed in greater numbers than cataract surgery. Many believe these errors could be underreported because they do not often cause substantial harm.

Identifying Errors

In the retrospective small case series, the investigators examined a convenience sample between 2019-2020. Cases of errors in intravitreous injection were identified as either part of a formal institutional quality review or by self-report of the involved surgeon during quality improvement discussions.

The investigators sought main outcomes of the description of the medical errors and the circumstances surrounding these errors.

There were more than 147,000 injections performed at KPNC within the two-year evaluation period. The team found 4 cases of errors in intravitreous injections during the study period that were associated with inaccurate reviews of electronic medical records, poor surgeon and staff focus, and inconsistent use of surgical checklists and timeouts.

There was no long-term ocular morbidity following any of the errors.

“Given the large volume of intravitreous injections performed by retinal specialists in office-based settings, it is unsurprising that cases of wrong intravitreous injections occur,” the authors wrote. “Although none of our reported cases of wrong injections resulted in harm, these errors have the potential to cause substantial ocular morbidity, particularly if a complication such as endophthalmitis occurs.”

Limiting and improving errors could help patients maintain trust in their treating physician.

Case Reports

The first case report involved a patient who underwent treatment for neovascular age-related macular degeneration in both eyes with the same anti-VEGF treatment, but on different treatment intervals.

The error occurred when the surgeon misread the last note and informed the staff to prepare the wrong eye for injection.

The second incident also involved a surgeon injecting in the wrong eye.

This patient had a history of branch retinal vein occlusion in the right eye, but the surgeon accidentally made the injection in the left eye.The third and fourth examples were patients that either received the wrong medicines or the wrong medication dose.

“Medical errors related to intravitreous injections have occurred within KPNC,” the authors wrote. “We trust these events are not unique to our practice. A standardized teams-based approach that incorporates rigorous safety protocols will likely be needed to reduce the risk of future wrong intravitreous injections.”

The study, “Evaluation of a Series of Wrong Intravitreous Injections,” was published online in JAMA Ophthalmology.

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