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Related Experiment Video

Updated: Feb 26, 2026

Author Spotlight: Enhancing Visual Outcomes in Cataract Surgery: A Novel Technique to Prevent Posterior Capsular Opacification Through IOL Rotation
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Reducing wrong intraocular lens implants in cataract surgery.

Huey Peng Loh1, Dirk Frans de Korne1, Soon Phaik Chee1

  • 1Singapore National Eye Centre, Singapore.

International Journal of Health Care Quality Assurance
|July 18, 2017
PubMed
Summary
This summary is machine-generated.

The Systems Engineering Initiative for Patient Safety (SEIPS) framework reduced wrong intraocular lens (IOL) implants in cataract surgery. This patient safety initiative decreased IOL errors and near misses, improving surgical outcomes.

Keywords:
Clinical risk managementError analysisIncident reportingPatient safetyRoot cause analysisSystem thinking

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Area of Science:

  • Patient Safety
  • Surgical Quality Improvement
  • Systems Engineering in Healthcare

Background:

  • Wrong intraocular lens (IOL) implants represent a significant medical error in cataract surgery.
  • Existing systems often lack comprehensive approaches to prevent such errors.
  • Cataract surgery involves complex steps, increasing the risk of IOL mix-ups.

Purpose of the Study:

  • To evaluate the effectiveness of the Systems Engineering Initiative for Patient Safety (SEIPS) framework.
  • To implement and assess sustainable interventions for reducing wrong IOL implants.
  • To analyze the impact of SEIPS on patient safety in cataract surgery.

Main Methods:

  • A mixed-methods study utilizing the SEIPS framework.
  • Analysis of near-miss and actual wrong IOL implant incidents.
  • Risk assessment audits conducted pre-, during, and post-intervention (2012-2015).

Main Results:

  • Significant reduction in wrong IOL implant rates (4.91 to 2.54 per 10,000 cases).
  • Decrease in near-miss IOL errors (5.89 to 3.55 per 1,000 cases).
  • Identified a wide variety of IOL types and vendors as a key root cause.

Conclusions:

  • The SEIPS framework effectively supports the development of sustainable quality and safety interventions.
  • SEIPS aids in addressing both person- and system-related root causes of medical errors.
  • Implementation of SEIPS fosters a stronger culture of quality and patient safety in surgical settings.