Abstract
PURPOSE: At the Kellogg Eye Center, we identified a series of injection-related patient safety events that led to a systematic review and redesign of our intravitreal injection protocol. The objective was to reduce injection-related patient safety events to zero. METHODS: A retroactive review, using the Healthcare Failure Mode and Effect Analysis model as a guide, was performed on our process for delivering intravitreal injections to identify potential failure modes and their impact. RESULTS: The total number of injection-related safety events was 1 in 2017 and 16 in 2018 at baseline. Potential vulnerabilities identified included errors in communication, patient identification, clinical documentation, and medication orders. The injection protocol was redesigned. After implementation, there were zero injection-related safety events in all Kellogg Eye Center Retina clinics for the subsequent 18-month follow-up period. CONCLUSION: It is possible to redesign and implement an intravitreal injection protocol to reduce the rate of safety events in a large academic eye center.