picked the wrong model lens and then verified it. That's one of the les-
sons we learned: Don't have the same person who picks the lens veri-
fy the lens. But because it was late in the day, no one else was avail-
able to pick the lens. Usually, if a room breaks for an hour, the nurses
and techs from that OR will pick lenses.
Here's the really odd part. The nurse who picked the lens and verified
it on Friday was also assigned to the room on Monday. What are the
odds?
When we do a time out, the nurse takes the lens order sheet and
reads the surgeon's orders out loud. She also shows the implant box
to everyone and reads the label to confirm what it is. A tech noticed a
discrepancy and asked for a hard stop. "Confirm the box, please," she
said.
The nurse read off the box: ZCT225. "Don't you want a ZCT150?"
asked the tech. "Please confirm the lens on the order sheet."
The order sheet was correct. We had pulled the wrong lens. Clearly,
no one was paying attention when they signed the lens order form.
We pulled the correct lens from a cabinet in the hallway and implant-
ed the correct IOL.
Lessons learned
We did a full root cause analysis on our near miss and made 5 correc-
tive actions.
• The nurse who picks can't verify. For lens orders received less
than 5 business days before surgery, the person who picks the lens
cannot be the same person who verifies it. Also, when we receive
the lens order 24 to 48 hours before surgery, techs can pick lenses,
but only nurses can verify lenses in the OR corridor. We felt it best
to let RNs confirm that the lenses match the OR schedule.
• Pick 1 lens order sheet at a time. We standardized how we pick
Safety
S
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