HSJ Patient Safety Awards 2017: Clinical Governance and Risk Management in Patient Safety

A cluster of patients presented with ocular pain and reduced vision after cataract surgery and were found to have either corneal melting or epithelial breakdown. All patients were prescribed a commonly used post-operative eye drop combination which was considered the causative factor.

An immediate investigation determined the exact number of affected cases. These patients and The Medicines and Healthcare Products Regulatory Agency, RCOphth and UK Ophthalmic Pharmacists Group were informed to ensure that use of the combination stopped.

This case series was presented at the European Society of Cataract and Refractive Surgeons Annual Congress in order to expose the potential adverse outcomes of these medications internationally.

The judges said this submission met the brief in every way and was an extremely robust, swift and patient focused response to a rare and unusual event. The way the leadership and the organisation took around the issue is admirable.

Highly commended was Spectrum Community Health Community Interest Company.