Significant events in ocular oncology

Significant events relating to the operation of the service such as loss to follow up or delayed follow up of a patient with an ocular tumour should be reported via local reporting mechanisms.

“Wrong site” (eg wrong side, wrong procedure) surgery is classified by the NHS as a “never event” and must always be reported and investigated fully using root cause analysis techniques.   The College recommends routine use of a preoperative checklist such as the WHO / NPSA “safer surgery” checklist to reduce the likelihood of such events .   Other serious events such as radiation under-treatment or over-treatment due to miscalculation of dose, or malfunction of equipment leading to harm of a patient require similar reporting to the relevant authorities and investigation.