Case study: Retention of Mydriasert insert post ophthalmic surgery

Through its review of recorded patient safety events the National Patient Safety Team identified a risk of harm from retained Mydriasert® inserts after ophthalmic surgery, after receiving a report where an insert was removed 6 days after surgery by a patient’s relative.

Mydriasert® is an insoluble ophthalmic insert used to dilate the pupil of the eye prior to surgery. It is intended to be removed prior to the procedure, and within two hours of insertion.

A search of the National Reporting and Learning System (NRLS) database revealed a further eleven incident reports where inserts had been left in place. We consulted with the Royal College of Ophthalmologists (RCOphth), who issued a Safety Alert which included recommendations to manage the process of insertion, removal and record keeping.

RCOphth also worked with the supplier of Mydriasert® inserts to help further reduce the risk by producing an aide memoire infographic (which was embedded within the Safety Alert) illustrating the process for clinical management.

About our patient safety review and response work

The recording and central collection of patient safety events to support learning and improvement is fundamental to improving patient safety across all parts of NHS healthcare. The National Patient Safety Team identify new or under recognised patient safety risks, which are often not obvious at a local level. It does this through its core work to review patients safety events recorded on national systems, such as the National Reporting and Learning System (NRLS), the new Learn from Patient Safety Events service (LFPSE), and other sources.

In response to any newly identified risks, we develop advice and guidance, such as National Patient Safety Alerts, or work directly with partners as in the example above, to support providers across the NHS to take the necessary action to keep patients safe.

You can find out more about our processes for identifying new and under recognised patient safety issues on our using patient safety events data to keep patients safe and reviewing patient safety events and developing advice and guidance web pages.

You can also find more case studies providing examples of this work on our case study page.