RED ZONE A nurse wears a red bouffant while picking and verifying lens implants in the OR corridor at the Garden City (N.Y.) SurgiCenter. The red bouffant lets staff and surgeons know that they're not to interrupt the nurse picking lenses for any reason.

At a busy cataract facility like ours, a simple misstep is all it takes to implant the wrong-powered intraocular lens. But we were confident that we'd pick and verify the right IOL for each and every one of the 5,000-plus cataract cases we perform a year. We thought our 3-level system of verification and our time out practices were foolproof. We thought wrong.

There was a crack in our system just wide enough for a wrong-site surgery to fall through. Not long ago, we ordered and pulled the wrong intraocular lens, and were seconds away from inserting an AMO ZCT225 11.5D instead of an AMO ZCT150 11.5D. Luckily, we caught the near-miss in the nick of time, thanks in large part to the courage of a vigilant tech who spoke up at the last second when she sensed something was wrong. Since our near miss, we've shored up the crack in our system — and learned some valuable lessons.

Here's what our verification system looks like. We confirm 3 times that the lens model and power the surgeon ordered matches the lens that we pick. This doesn't include the time out that we conduct in the OR.

Our policy states that the surgeon should have the lens order in at least 5 days before surgery. About 10% of our docs don't meet this timeframe for various reasons. Maybe the patient didn't go in for her biometer testing yet so we don't have the IOL power calculation. Maybe the doc's on vacation.

We have to have 2 of the lenses that the surgeon orders in stock — 1 as the primary and the other as a backup in case we drop the primary on the OR floor. Once we get the lens order form, we pull the lens and wrap the form around the package. The nurse that picks the lens signs the form to confirm that the lens we ordered matches the lens that will be present in the OR for the case.

About 24 to 48 hours before surgery, we verify for a second time that all the lenses we picked for the next day's cases match the lenses that our surgeons ordered, that they're present (meaning, they're on site in the facility) and that the laterality matches what's noted on the OR schedule (we usually do 40 to 50 cases a day).

On the day of surgery, when the patient goes into the OR, a nurse takes the picked lens with the lens order sheet rubber-banded around it into the OR. She signs off and confirms that yes, the doctor ordered this lens. Together the surgeon and nurse confirm that the lens is correct and then stamp and sign the form to indicate as much.

Then there's the final confirmation during the surgical time out. A nurse confirms that the lens she's holding matches what the doc ordered and everyone in the room — the anesthesiologist, surgeon, surgical tech and RN — must agree.

SOLE FOCUS Staff now pick one lens order a time. After they pick the lens, they wrap it with a signed order sheet, as shown here.

Pulled the wrong IOL
It's hard to imagine an error slipping through, but it did. The lens order came in on a Friday afternoon for a Monday morning surgery. By some fluke in the schedule, the nurse that got the order on Friday was also the nurse who would verify the lenses for the next day. She picked the wrong model lens and then verified it. That's one of the lessons we learned: Don't have the same person who picks the lens verify the lens. But because it was late in the day, no one else was available 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 implanted the correct IOL.

Lessons learned
We did a full root cause analysis on our near miss and made 5 corrective 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 lenses. Before, some staff would pick 10 or 15 lens orders at a time, while others would pull all the orders and start wrapping them. Now we concentrate on 1 lens order at a time: You pick the lens, sign off that you picked it and then you wrap it. That way, you're focused on 1 implant at a time and can concentrate on 1 lens order at a time.

Make the person the red zone. We pick lenses in the middle of a hallway between cases in the middle or at the end of the day. There are cases going on. The OR corridor is buzzing with conversation. We can't make the OR corridor a "red zone," but we can make the person picking lenses be a red zone by having her wear a red bouffant that signifies she's in a quiet zone and you're not to disturb her for any reason while she's picking lenses.

Red zone verification. We take nurses who are verifying lenses 24 to 48 hours before surgery out of the corridor if we can and set them up in a medication room or an empty OR so they can work in quiet.

Be engaged. When you're doing more than 5,000 cataract cases a year, it's easy to go through the motions. When the surgeon checks the stamp that says the lens picked matches the lens ordered, he signs it. But does he read it? We stress the importance of being fully engaged in what you're doing. OSM