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A QI Project: Reducing intraocular lenses misplacement in OT


Intraocular lens (IOL) is a crystalline lens implanted in the eye as part of treatment for cataract surgeries. Annually, SNEC performs approximately 10,000 cataract surgeries. Continuous advances in medical technology has improved quality of IOLs for better patient outcomes. It is now possible to have different sorts of lens supplied by different companies to satisfy different patient’s needs. These IOLs are packaged in a similar manner and may have similar sounding names. 


        Previous IOL cabinet with no signage                         Look alike IOL packaging being place at the wrong slot                   After large signage was implemented

How did this idea come about?

While out shopping one day, SSN Cynthia Wilson noticed how clear displays and big signage at her supermarket helped her to locate what items they hoped to buy with ease and from afar. She felt how the IOL cupboards at Operating Theatre (OT) could be similarly organized. Together with her IOL team, SSN Cynthia integrated what she learned from the supermarkets and added a clear labelling system to improve ease of storage, and stock-taking of IOLs. This simple re-organization of the system made a big difference. Staff immediately appreciated how the system improved housekeeping, prevented misplacement in the IOL cabinets, made it easier to find the correct IOL required, and improved efficiency and safety of all concerned.

What happens if IOLs are misplaced?

It is the case when one error could add to another. If the IOL is misplaced, then the staff retrieving it later for surgery may pick up the wrong IOL. If so, patient’s safety may be compromised if the error is not detected further down the line. Placing a wrong IOL into the patient’s eye may result an unexpected patient outcome with complex medical, financial and administrative consequences.

If the source of the error cannot be specifically identified, this may negatively affect workflow and trust. including financial and administrative function. Hence, it is important to have an effective system in place to prevent mishaps from occurring.  

What is the outcome for this implementation?

After the implementation, the team is proud to report a positive result. With the colour coded large front signage, misplacement of IOL model into the wrong slot was reduced by 70% while the time efficiency for staff to retrieve and locate the IOL increased by 80%.

Although the new system may not have completely eradicated accidents, it’s contribution in minimising human error and cultivating good habits cannot be overstated. The team witnessed significant progress in error reduction and have observed a positive shift in work performance. This was an excellent outcome and very important when staff are working in a fast paced environment.

As the team continue to refine and optimise the system, they are committed to identifying and addressing any remaining areas of concern; working towards their ultimate goal of achieving error-free operations.

What are the challenges the team faced?

The main challenge was communicating the purpose and nature of the change to ensure that everyone is aware of the change, are properly trained and will continue to comply with the new processes.

Do you think this project is sustainable?

Of course! It is a BIG YES! Though the IOL cabinet was replaced by a digital-smart cabinet, the staff still used the signage to locate the IOL model and return the IOL to the correct slot.

How do you think the project can be improved further?

A new robotic machine which can store up to 1,500 pieces of IOLs is undergoing development. This robot reduces the manual work of returning unused IOL, stock loading, inventory thus decrease error made by human, increase patient safety and also time saving.

What did the team learn from this project?

What we see every day can be used to make a simple change that can hugely impact our lives. Hence, not to take the simple things in our everyday life for granted.

The IOl team: From Left SN Celine Tay, SSN Cynthia Wilson and SN Claudia Goh

Contributed by:


 SSN Cynthia Wilson
 Senior Staff Nurse
 Nursing, Operating Theatre
 Singapore National Eye Centre


 SN Claudia Goh
 Staff Nurse
 Nursing, Operating Theatre
 Singapore National Eye Centre

 SN Celine Tay
 Staff Nurse
 Nursing, Operating Theatre
 Singapore National Eye Centre

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