Verification Protocols Increase Intravitreal Injection Safety

Surgeon talking with nurse during optical surgery in modern clinic
Surgeon talking with nurse during eye operation of a male patient at hospital. Ophthalmologist discussing with assistanct during an optical surgery in eye clinic.
Clinicians analyzed root causes of factors that contributed to possible patient safety events.

Recognizing safety risks and root causes, and addressing them with quality improvements, can increase patient safety in practices that perform intravitreal injections, research published in Ophthalmology Retina suggests.

While prior studies have indicated high numbers of medical errors associated with surgical procedures, few studies have reported the frequency of medical errors in intravitreal injections. In this study, researchers at Mayo Clinic Rochester’s high-volume intravitreal injection clinic used root cause analysis to evaluate how to decrease risk of patient harm and assess the effectiveness of their interventions.

Retina specialists, who determined and documented treatment plans, and comprehensive ophthalmologists administered intravitreal injections in a doctor-of-the-day model. Nurses prepped patients with intravitreal injections according to treatment orders and documented patient safety events.

The clinic’s injection practice process underwent a Six Sigma quality improvement plan to reduce patient safety events in 2018. Past patient safety events (9.3 events per year, 28 patient safety events from 27,400 injections) and potential contributing factors were collated and categorized to identify root causes. Modifications were established for 2019.

The 28 patient safety events included 3 never events that did not result in patient harm (1 wrong eye because of misinterpretation of complex treatment plan 1 wrong eye because of misreading previously administered injections 1 wrong procedure based on incorrect timing of an injection triggered by patient schedule changes) and 25 near misses related to laterality (n=11), medication (n=10), or timing of injection (n=4).

Root causes contributing to patient safety events included treatment plans that were difficult to interpret because of variations in treatment, schedules, documentation, or complexity; insufficient treatment plan review time; and lack of designated channels for communication and coordination. Staff were concerned about the risk of human error due to high volume and pace of injections and ability to quickly find data in medical records.

The intervention consisted of making documentation practices simpler and more consistent, providing doctors documentation review time several hours prior to clinic opening, and advancing initial site verification, via ipsilateral wristband, to vision screening examination prior to handoff. The injecting physician and a designated allied health coordinator communicated to resolve any discrepancies in their findings.

After intervention, the annual event rate decreased from 0.1% to 0.01% (P =.01), with 1 near miss without patient harm. The near miss was related to laterality and occurred within 1 month of intervention, the researchers reported.

The researchers recommended intravitreal injection practices analyze patient safety issues particular to their workflow and act to minimize the risk of patient harm.

Limitations of the study included lack of cost-analysis and unknown role of increased awareness the quality improvement project prompted.

Disclosure: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. This research was supported by Mayo Foundation for Medical Education and Research. Please see the original reference for a full list of authors’ disclosures.


Patel SV, Olsen TW, Hinchley RL, et al. Improving patient safety in a high-volume intravitreal injection clinic. Ophthalmol Retina. Published online February 11, 2022. doi:10.1016/j.oret.2022.02.002