Patient had wrong eye injected after software error

Herefordshire clinicians injected a patient in the wrong eye after a technical blunder, board papers have revealed.

The Wye Valley Trust patient was injected with an antivascular endothelial growth factor to treat age-related macular degeneration. They did not come to harm as a result of the incident.

The mistake occurred after the ophthalmology department deleted a poor quality image of one of the patient’s eyes. This shifted up the other images, which were stored sequentially using software called IMAGEnet6, which led to the mistake. 

Although initially reported as a “never event,” the incident was downgraded to a “serious incident” after a review by the Herefordshire Clinical Commissioning Group (CCG). 

The trust, which is still using the software, is updating its standard operating procedure and has installed new technology that can take higher quality images. A spokesman said: “Patient safety is the trust’s priority. While no harm was caused to this patient, the trust has taken this incident seriously.”

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Source: HSJ, 21 January 2020