Supporting guidance for optometrists reporting serious incidents
A serious incident may be defined as ‘Any unintended or unexpected incident which could have or did lead to harm for one or more patients receiving NHS funded healthcare’.
Definition of vision loss
The definition of harm due to delay was defined as a deterioration of vision in at least one eye of 3 lines of Snellen acuity (or 15 letters on an ETDRS chart) or deterioration in the visual field of 3 decibels or patients whose vision has deteriorated to below that measured on the Snellen Chart to Counting Fingers or worse due to a health service initiated delay in ophthalmic review or care (Foot & MacEwen 2017. Eye 31, 771–775)
Harm severity classification
Adapted from the WHO definitions (Cooper et al. 2018 Bull World Health Organ. 2018;96(7):498-505), these definitions can be used to think about the physical, social and psychological implications for your patients and their families. Moderate harm is distinguished from mild harm, in that it would require a greater level of physical intervention/referral, whilst severe harm would result in vision loss as defined.
Incident occurred but no harm experience by patient or lack of appropriate instrumentation / inaccurate calibration of instrument.
harmed with mild and short-term impact on procedure-related trauma e.g. corneal abrasion requiring prescribing of ocular lubricant and/or chloramphenicol in response, no or minimal pain o repeat of minor procedure e.g. removal of residual rust ring.
medium term impact on clinician or action leading to treatment for corneal disruption in response to hydrogen peroxide or rigid lens cleaner o missed reason for referral resulting in delay to secondary care with no lasting adverse consequence e.g. mild/moderate pain or delay in operation o routine referral not received / loss to follow up with no lasting adverse consequences.
Permanent impact o Patients experiencing irreversible sight loss due to a delay in review or treatment or inability to access secondary care in a timely manner o Missed reason for referral resulting in delay to secondary care leading to vision loss of medication non-adherence resulting in disease progression or vision loss.
Probability of recurrence
|Frequent||Is expected to occur again either immediately or within a short period (likely to occur most weeks or months).|
|Likely||Will probably occur in most other practices in similar circumstances (several times a year).|
|Possible||Might possibly recur in our practice and in other practices – might occur at some time (may happen every 1 to 2 years).|
|Unlikely||Possibly will recur – could occur at some time in 2 to 5 years.|
|Rare||Unlikely to recur – may occur only in exceptional circumstances (may happen every 5 to 30 years).|