Table 2. Free text reports; examples from selected PSI reports by theme.

Incident theme	Incident text as reported	Incident severity as reported
Endophthalmitis	• Patient admitted following Avastin injection (date stated) to operating theatre for right vitreous tap with antibiotics—repeated on (another date stated) and may need further surgery.	Severe
Wrong injection	• Patient seen by consultant in clinical room after visual acuity had been checked. Patient was due for second Lucentis injection. Consultant then saw 3 more patients. Patient then taken into AMD room for procedure and consented by consultant. Prepared for procedure and injected left eye. Health care assistant came in and pointed out wrong eye but already injected. Patient escorted to waiting area.	Low
	• 0.5 ml intravitreal lidocaine given in error, thinking it was the Lucentis injection syringe. Afterwards intravitreal Lucentis injection given as normal.	No harm
Medication supply and storage	• The pharmacy has only one available Lucentis injection for 2 cases. Apparently the ordered drug has not come in time for case this morning hence we have to cancel one patient.	Moderate
	• Drug fridge was off all weekend and noted at 11:30 to be at 20C. The fridge temperature is checked daily and was in working order on the previous Friday. 2 syringes of ranibizumab had been issued on Monday morning before the fridge temperature had been discovered. 2 patients were given the injection.	No harm
Error in follow up	• Patient having 3 initial injections of Lucentis, put down for review one month after the 3rd but was not given appointment till nearly 3 months after this. He needed monthly treatment but his follow up was not on time due to busy clinics.	Moderate
	• 40 Patients identified who had received intravitreal ranibizumab therapy earlier than the recommended 28 day interval since (date stated). Patients were identified retrospectively and to date there has been no adverse medical outcome.	None
	• Patient attended AMD services on (date stated). Diagnosis bilateral AMD. Plan of treatment right and left Lucentis intra vitreal injection. Left eye to be treated first. At this stage left eye was treatable. Patient put on waiting list next available date being 26 days following. On this day left eye visual activity reduced to 8 letters only therefore too much vision lost and treatment no longer viable. Only treatment could be given to the right eye.	Severe

Reports are largely in the unedited words of reporters. Any identifiable dates or place names have been removed.