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Lessons from implementation of an intraocular lens timeout

Lee, Bryan S. MD, JD; Chen, Philip P. MD

Journal of Cataract & Refractive Surgery: October 2014 - Volume 40 - Issue 10 - p 1744-1746
doi: 10.1016/j.jcrs.2014.08.015
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In both the medical and lay literature, use of checklists and timeouts has gained wide support as an adaptation of safety processes from airlines and other industries.1,2 One of the most common errors in ophthalmology is insertion of the wrong intraocular lens (IOL), which is a major source of patient dissatisfaction and malpractice litigation.3,4 Although innovations such as intraoperative aberrometry aim to improve the accuracy of IOL selection, this added information makes it even more critical to verify that the intended IOL is the one inserted. Although multiple IOL checklists are publicly available, there are scant data on the success of their implementation.

At the University of Washington, an IOL timeout was mandated in July 2012. The protocol requires the circulator to verify the patient’s name on the IOL sheet preoperatively and cross off the nonoperative eye. It also requires the surgeon and circulator to pause during the case before the IOL is opened to check the IOL sheet and to confirm the patient, eye, and IOL type and power.

Approximately 6 months after timeout implementation, all resident and attending physicians (other than the first author) who perform cataract surgery at the Eye Institute were invited to take an online survey as part of the department’s quality improvement process. Another survey was sent to all staff who take part in cataract surgery.


The response rate was 100% for attending surgeons (n = 8), 75% (6/8) for residents, and 100% for staff identified by the nurse manager as most frequently involved in cataract cases (n = 15). Many more staff members give occasional breaks in the hospital operating room setting, so 107 in total were invited to participate (23.3% response rate).


All attending surgeons agreed or strongly agreed that they performed the timeout consistently, and 79% agreed it was useful. Thirty-six percent of attendings did not identify the patient and 21% the operative eye as essential timeout elements, and 43% did not agree they felt adequately trained (Table 1). However, 1 attending decided to change the IOL power in 1 case during the timeout, and 1 resident reported that the supervising attending changed the resident’s IOL selection during the timeout.

Table 1
Table 1:
Attending and resident surgeon responses.

Operating Room Staff

Ninety-two percent of staff agreed the timeout was useful and 84% that it was always performed (Table 2). However, 48% did not agree it was performed consistently. Twenty-eight percent did not identify the patient and 24% the operative eye as essential timeout elements, and 64% had difficulty identifying the intended IOL from the calculation sheet. Multiple respondents indicated that standardization of specifying the intended IOL would be helpful. Eighty-four percent felt comfortable stopping a surgeon to enforce the timeout, and 48% had actually done so (mean 3.5 times each).

Table 2
Table 2:
Operating room staff responses.


The IOL timeout was well accepted by both surgeons and staff, and there were cases in which the timeout resulted in thoughtful reconsideration of which IOL to implant. However, this survey also highlights areas for improvement.

Clearly, one-time implementation of a safety measure such as the IOL timeout is inadequate. Quality improvement must be continuous, with evolving protocols, regular reminders, and processes for training newcomers. Continuous training might have increased awareness that patient name and eye were necessary timeout elements, a requirement arising from the fact that IOL errors have occurred from using the wrong patient’s IOL sheet and the nonoperative eye’s calculations.3 Standardization increases the usefulness and protective benefit of safety steps such as timeouts,5 so uniform identification of the intended IOL may help the two-thirds of staff who could not interpret the IOL sheet. Standardization would also prevent a drop-off in safety and quality with operating room staff who participate in cataract cases infrequently.

This study cannot determine whether there is additional benefit in pausing to focus on IOL selection just before implantation rather than preoperatively. However, this may be especially valuable in a training environment such as ours in which sulcus or anterior chamber IOL implantation happens relatively more frequently.

Although the timeout is a useful tool, it is even more important to create a culture of safety, and we hope this correspondence encourages further innovation toward the goal of total elimination of IOL errors.


1. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, Sexton B, Hyzy R, Welsh R, Roth G, Bander J, Kepros J, Goeschel C. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355:2725-2732. correction 2007; 356:2660. Available at:; correction available at: Accessed May 25, 2014.
2. Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat A.-H.S, Patchen Dellinger E, Herbosa T, Joseph S, Kibatala PL, Lapitan MCM, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA., for the Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 360, 2009, p. 491-499, Available at: Accessed May 25, 2014.
3. Schein OD, Banta JT, Chen TC, Pritzker S, Schachat AP. Lessons learned: wrong intraocular Lens. Ophthalmology. 2012;119:2059-2064.
4. Brick DC. Risk management lessons from a review of 168 cataract surgery claims. Surv Ophthalmol. 1999;43:356-360.
5. Gawande A. The Checklist Manifesto; How To Get Things Right. 2010, Picador, New York, NY, 183
© 2014 by Lippincott Williams & Wilkins, Inc.