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