Objective: To report cases involving the placement of the wrong intraocular lens (IOL) at the time of cataract surgery where human error occurred. Design: Retrospective small case series, convenience sample. Participants: Seven surgical cases. Methods: Institutional review of errors committed and subsequent improvements to clinical protocols. Main Outcome Measures: Lessons learned and changes in procedures adapted. Results: The pathways to a wrong IOL are many but largely reflect some combination of poor surgical team communication, transcription error, lack of preoperative clarity in surgical planning or failure to match the patient, and IOL calculation sheet with 2 unique identifiers. Conclusions: Safety in surgery involving IOLs is enhanced both by strict procedures, such as an IOL-specific "time-out," and the fostering of a surgical team culture in which all members are encouraged to voice questions and concerns. Financial Disclosure(s): The author(s) have no proprietary or commercial interest in any materials discussed in this article.
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