A review of safety incidents in England and Wales for vascular endothelial growth factor inhibitor medications

Source: Eye
Area: Evidence > Medicines Management > References
Purpose: To learn from patient safety incidents (PSIs) following recent introduction of vascular endothelial growth factor inhibitor medications (anti-VEGF) in ophthalmic care, as reported via a national incident reporting database. Methods: Thematic retrospective review of anti-VEGF medications PSIs as reported via clinical incident reporting methods in NHS care in England and Wales from 2003 to 2010, ascertained from database mining at the National Patient Safety Agency (NPSA). Results: In all, 166 relevant anti-VEGF incidents were reported.  Reports have increased year on year from 2006.  Incident severity as reported: 10 were reported as 'severe harm' and 23 as 'moderate harm'.  The remainder were 'low' or 'no harm' events.  The incident themes and/or causes found and by order of severity included: intra-ocular inflammation/endophthalmitis (n = 16); treatment or follow-up delays (n = 45); wrong medication (n = 26); wrong eye/patient injection (n = 17); ...