- Clinicians injected wrong eye after deleting an image
- Deletion of picture altered sequence of images, leading to error
- Trust says it reported ongoing issues to software supplier Topcon prior to the incident
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.
According to the board papers, the department said its clinicians had followed technical guidance. A Wye Valley spokeswoman told HSJ it had previously reported ongoing problems regarding sequencing and poor image quality to software supplier Topcon. The trust, which did not report this specific event to Topcon, was not aware of any other incidents related to the software.
Topcon was unable to confirm the receipt of Wye Valley’s reports or its response to them before press time. When asked for details of all reports regarding the software, the Medicines and Healtcare products Regulatory Agency said it could not provide any information that would identify a manufacturer.
Although initially reported as a “never event,” the incident was downgraded to a “serious incident” after a review by the Herefordshire Clinical Commissioning Group.
A CCG spokeswoman said commissioners were still investigating the incident and are awaiting the submission of a full report from the trust.
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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Wye Valley Trust January board papers, information obtained byHSJ