The Non-Hospital Medical and Surgical Facilities Accreditation Program Patient Safety Incident Review Panel recently reviewed a patient safety incident involving an incorrect printout of toric lens calculations that resulted in the patient requiring a second procedure to reposition the lens.
The errors noted in the printout were reproducible on the company toric calculator website by using the back and forward buttons. This website design error was brought to the attention of the company which indicated that if the Confirm Inputs and Calculate Lens buttons are used, the error does not occur. The use of the back button to return to the inputs page is expected and correct. The error occurs when the browser forward button is used to return to the results page. The company recommends that until the error is corrected, the browser forward button should not be used and the Calculate Lens button should be used instead. The company has informed their sales force to notify customers of this potential issue.
This case highlights the importance of review of the surgical plan prior to the day of surgery to double check calculations and avoid input errors.
Facilities with further questions or concerns should contact their respective sales representative.