The Healthcare Safety Investigation Branch (HSIB) has released an interim bulletin relating to their investigation on the insertion of an incorrect intraocular lens.
The HSIB were made aware of an 86-year old woman who had the wrong lens
inserted during cataract surgery. The initial investigation discovered that,
despite national guidance and recommendations, these Never Events continue to
occur. The full investigation will continue to explore the identified safety
issues and seek to identify strategies and opportunities to reduce the
frequency of this event.
Interim bulletins are released to share further details of each
investigation, including how it’s met HSIB criteria, the history of the event
it relates to, the national context and any identified safety issues.
The HSIB launched its first full investigation in July 2017 and is now carrying out nine full investigations.
Download the bulletin here