Importance This case series describes events associated with errors in intravitreous injections. Given the volume of injections performed worldwide, it is important to identify the factors associated with these wrong events to try to reduce their occurrences.

Objective To evaluate a series of errors in intravitreous injections within Kaiser Permanente Northern California (KPNC).

Design, Setting, and Participants In this retrospective small case series of a convenience sample at KPNC between January 1, 2019, and December 30, 2020, cases of errors in intravitreous injection were identified either as part of a formal institutional quality review or by self-report of the involved surgeon during quality improvement discussions.

Main Outcomes and Measures Description of the medical errors and the circumstances surrounding these errors.

Results During the 2 years of this evaluation, there were more than 147 000 injections performed within KPNC. Four cases of errors in intravitreous injection were identified. Mistakes were associated with inaccurate review of the electronic medical record, poor surgeon and staff focus, and inconsistent use of surgical checklists and timeouts. No long-term ocular morbidity occurred following any of these errors.

Conclusions and Relevance Medical errors related to intravitreous injections have occurred within KPNC. We trust these events are not unique to our practice. A standardized teams-based approach that incorporates rigorous safety protocols will likely be needed to reduce the risk of future wrong intravitreous injections.

重要性 本案例系列描述了与玻璃体内注射错误相关的事件。鉴于世界范围内进行的注射量，重要的是要确定与这些错误事件相关的因素，以尽量减少它们的发生。

目的 评估北加州凯撒医疗机构 (KPNC) 内玻璃体内注射的一系列错误。

设计、设置和参与者 在 2019 年 1 月 1 日至 2020 年 12 月 30 日期间 KPNC 便利样本的回顾性小型病例系列中，玻璃体内注射错误病例被确定为正式机构质量审查的一部分或由自己确定- 在质量改进讨论期间相关外科医生的报告。

主要结果和措施 描述医疗差错和这些差错周围的情况。

结果 在本次评估的 2 年中，在 KPNC 内进行了超过 147 000 次注射。确定了四例玻璃体内注射错误。错误与电子病历审查不准确、外科医生和工作人员注意力不集中、手术检查表使用不一致和超时有关。在任何这些错误之后都没有发生长期的眼部疾病。

结论和相关性 KPNC 内部发生了与玻璃体内注射相关的医疗错误。我们相信这些事件并不是我们的实践所独有的。可能需要一种基于团队的标准化方法，该方法包含严格的安全协议，以降低未来错误玻璃体内注射的风险。