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Brief Report
August 26, 2021

Evaluation of a Series of Wrong Intravitreous Injections

Author Affiliations
  • 1Kaiser Permanente Northern California, Oakland
JAMA Ophthalmol. 2021;139(10):1123-1125. doi:10.1001/jamaophthalmol.2021.3311
Key Points

Question  How did cases of wrong intravitreous injection occur within Kaiser Permanente Northern California?

Findings  In this case series of 4 patients identified over 2 years among more than 147 000 intravitreous injections, inconsistent use of safety practices such as pre-procedural checklists and timeouts were associated with wrong-eye and -medication intravitreous injections.

Meaning  These cases emphasize the need for implementing and consistently following rigorous measures to decrease the risk of wrong injections.


Importance  This case series describes events associated with errors in intravitreous injections. Given the volume of injections performed worldwide, it is important to identify the factors associated with these wrong events to try to reduce their occurrences.

Objective  To evaluate a series of errors in intravitreous injections within Kaiser Permanente Northern California (KPNC).

Design, Setting, and Participants  In this retrospective small case series of a convenience sample at KPNC between January 1, 2019, and December 30, 2020, cases of errors in intravitreous injection were identified either as part of a formal institutional quality review or by self-report of the involved surgeon during quality improvement discussions.

Main Outcomes and Measures  Description of the medical errors and the circumstances surrounding these errors.

Results  During the 2 years of this evaluation, there were more than 147 000 injections performed within KPNC. Four cases of errors in intravitreous injection were identified. Mistakes were associated with inaccurate review of the electronic medical record, poor surgeon and staff focus, and inconsistent use of surgical checklists and timeouts. No long-term ocular morbidity occurred following any of these errors.

Conclusions and Relevance  Medical errors related to intravitreous injections have occurred within KPNC. 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.

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