ABSTRACT
Case 1: Optical Implant Error Members of the Virginia Mason board of directors received the news of the error 24 hours after the mistake occurred. The patient was scheduled for two consecutive procedures in the same eye. After the first surgeon operated and left the operating room to dictate notes, he realized he had implanted the wrong size lens in the patient’s eye. He went back to the OR, reported what had happened, and corrected the mistake.
