Chapter 7

A Very Different Kind of Board

Case 1: Optical Implant Error

Members of the Virginia Mason board of directors received the news of the error 24 hours after the mistake occurred. The patient was scheduled for two consecutive procedures in the same eye. After the first surgeon operated and left the operating room to dictate notes, he realized he had implanted the wrong size lens in the patient’s eye. He went back to the OR, reported what had happened, and corrected the mistake.

This case resulted in a red patient safety alert (PSA), and all such alerts are promptly reported to board members. In this case, the analysis of what had gone wrong was simple. Two implants—different sizes—were side by side on a tray in the OR. The corrective ...

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