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Publication Type: Risk Alert
Single or Multiple Incident: Single
Date: 4/1/2021 12:00:00 AM
Country: Hong Kong

This alert describes a patient safety incident of the wrong procedure used in ophthalmic surgery. A patient was followed up at eye clinic for diabetic retinopathy and maculopathy. As part of a series of macular laser treatment, the second macular laser treatment, the plan was to perform subthreshold micropulse grid laser to patient’s right eye in the second macular laser treatment. However, the micropulse function was not activated prior to treatment and 10 shots of conventional grid laser were given instead. The error was spotted after 2 seconds, when whitish laser marks were seen at the macula. The patient’s visual acuity of right eye remained unchanged though increased macular edema was noted. Sub-tenon injection of steroid and oral non-steroidal anti-inflammatory drugs (NSAID) were given. Contributing factors and recommendations to prevent similar incidents are provided.

Additional Details

Device:
laser
Medication/Gas/Fluid:
steroids, non-steroidal anti-inflammatory drugs (NSAIDs)


Wrong Laser Mode used in Macular Laser Treatment