Inappropriate administration of mitomycin in a cataract patient

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.