Risk Management



Triamcinolone Acetonide (Kenalog™ Triesence™ Trivaris™) Consent Form

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Perform a time out before each intravitreal injection.

OMIC has received reports of “wrong” events associated with intravitreal injections. These include wrong patient, wrong eye, wrong condition, wrong drug, and wrong dose.

To ensure that the correct drug and dose are injected into the correct eye every time, the ophthalmologist needs to lead a time out. Time out before intravitreal injections provides the opportunity to confirm that the patient, medical record, and ophthalmologist are in agreement.

 

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Patient’s Signature                                                                                                   Date

 

 

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