Quality of Eye Care

1. Problem: Wrong-eye procedures remain a critical “never event” driven by system gaps, not just human error
2. Intervention: Introduced eye-specific wristbands—but identified new risk in incorrect placement
3. Action: Standardized wristband application using a protocol and supporting device
4. Result: Errors reduced to 3 per 100,000 admissions (from 7 and 5 in prior years)
5. Impact: Continuous, system-based redesign is key to eliminating preventable harm

Human error is inevitable, and patient safety cannot rely solely on individual vigilance or clinical expertise. Preventing “never events, ” such as wrong-eye procedures, requires robust and reliable systems. Aravind Eye Hospital (AEH) implemented a structured patient safety framework incorporating systematic error reporting, root cause analysis, and continuous process improvement.

A patient safety committee was established at both central and departmental levels to oversee reporting, review incidents, and guide corrective actions. Regular training and awareness initiatives strengthened safety culture and improved reporting of near-misses and adverse events. As part of system redesign, wristbands indicating the eye scheduled for intervention were introduced to reduce the risk of wrong-site procedures. However, incorrect wristband placement emerged as an unintended source of error.

In response, AEH implemented a standardized protocol supported by a device to ensure correct wristband application and consistency across subsequent care processes. Following this intervention, wristband- related errors declined to 3 per 100,000 admissions in 2025, compared to 7 in 2024 and 5 in 2023, contributing to a reduction in wrong-eye interventions.

This initiative demonstrates that patient safety requires continuous monitoring, identification of unintended risks, and iterative system refinement to achieve sustained reliability.