Inappropriate administration of mitomycin in a cataract patient.

Purpose: This case report describes the improper administration of intracameral mitomycin after cataract extraction in an 83-year-old male, demonstrating the need for system improvements to prevent "never events." Observations: An 83-year-old male presented with visually significant bilateral cataracts, (right eye (OD): 20/80, left eye (OS): 20/70). He underwent technically uncomplicated cataract surgery in the right eye. At postoperative visit one, vision was 20/250 OD, less than anticipated for unclear reasons. On subsequent visits, the patient was found to have worsening photophobia, increasing conjunctival inflammation, corneal edema, and an elevated intraocular pressure of 27 mmHg. Given the variety and complexity of symptoms despite an otherwise uncomplicated surgery, an investigation was launched. An investigation for Toxic Anterior Segment Syndrome (TASS) revealed a mix-up between Cefuroxime and Mitomycin during medication preparation and administration. It was determined that mitomycin was inadvertently injected intracamerally into the patient's eye, causing intraocular toxicity and ultimately, loss of vision. Conclusions and importance: This case underscores the significance of system failures in the healthcare environment and how "never events" may occur even with appropriate protocols in place. The improper administration of mitomycin emphasizes the need for enhanced safety measures, including improved medication labeling, consistent use of time-outs, and reinforcing their importance in high-volume environments. System changes are essential to reduce the risk of errors and protect patient safety. The use of off-label, compounded medications should be minimized when possible. Ophthalmologists and the pharmaceutical industry should continue to seek an FDA-approved antibiotic for intraocular use in cataract surgery.