A female patient has an eye examination.

Insertion of an incorrect intraocular lens

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

National investigation

Cataract removal and implantation of an artificial lens is the most common surgical procedure undertaken by the NHS.

Insertion of an incorrect intraocular lens was the most commonly reported never event in England between April 2016 and March 2017. A never event is a serious incident that is entirely preventable.

Investigation summary

Initially the investigation focused on the hospital where the reference incident took place. During planned cataract surgery an 86-year old woman had the wrong strength lens implanted into her left eye. Her vision was not impaired as a result, but the case presented an opportunity to analyse local working practices, processes and pressures to identify the key areas for wider investigation.  

The broader investigation examined the usability of specialist ophthalmology systems and looked at how intraocular lenses are selected, retrieved and identified across organisations. The use and value of both international and national standards and guidance were also considered.

Investigation report