Patient safety in eye care: a multi-method analysis of reported incidents involving implementation of care and clinical assessment in England and Wales (13 February 2025)

Summary

Patient safety is a global health priority, yet there is limited research into how ophthalmology is responding to this. There is evidence that a review of patient harm related to eye care and the associated patient safety incidents is needed. This study aimed to characterise patient safety incidents involving eye care by: identifying the most frequently reported incidents involving clinical care; and characterising the nature of incidents leading to severe vision loss.

Of the 836 reports identified, insufficient care (416) and delayed diagnosis (234) featured most. Patient harm occurred related to vision loss (449), delays in treatment (182) and disease progression (121). Among 220 reports that resulted in severe vision loss, patients with glaucoma and age-related macular degeneration were impacted by delays in monitoring and management, loss to follow-up, disease progression due to insufficient care and system failures.