Authors (including presenting author) :
Poon SC(1), Wong YL(1)
Affiliation :
(1) Eye Centre, Prince of Wales Hospital
Introduction :
Eye Laser procedure is performed under "dimmed light" environment in busy clinic. SE (Wrong site laser procedure) happened in 2023 in PWH Eye Centre. After the incident, RCA panel was formed to investigate the incident & recommended improvement measures to minimize the risk. Before changes, eye marking was performed directly on patient's skin near forehead according to site marking guideline. However, the site marking was masked by the infection control protective plastic shield and the forehead band in a dimmed room. Under such condition, site marking was not obvious to laser surgeon during procedure in particular under dim light that may increase risk of performed wrong site laser procedure. Therefore, improvement plan was discussed in unit meeting & implemented according to RCA recommendation.
Objectives :
1) Enhance the workflow and optimize environment in laser room 2) Optimize the timeout procedure 3) Increase staff’ awareness and alertness of laser safety issues.
Methodology :
1) Removed the plastic shield to ensure clear visibility of marking site. 2) Enhanced Eye marking : Introduced microspore strips for marking to facilitate laterality verification. 3) Optimize environment for time out procedure : perform time out before dimmed light to provide a good sight. 4) Perform post implementation audit to evaluate outcome and compliance.
Result & Outcome :
1) Reviewed the effectiveness of new practice in enhance laser safety. 2) Laser Audit was performed from August to October 2024. The compliance rate was 100%.
