Thrilled to share our latest publication
You might not think that a Typhoon fighter jet squadron leader and a surgical team had much in common
Turns out there are many transferable skills & lessons to help improve patient safety!
👇
https://t.co/CTo4pE3qO0
Air traffic controllers, like healthcare professionals have periods of intense concentration, often work unsocial hours & make decisions critical for safety
Just finished writing an article with @BWheels_71@NATS about culture, performance & ways to help improve patient safety
Poor or miscommunication can compromise patient care & be a significant cause of error. It is implicated in up to 80% of NHS Never Events including wrong site surgery
Our case of the month highlights just what can happen with failed/poor communication
https://t.co/RDZbAdwClQ
Our new Case of the Month is now published
This describes a PICC line that was inserted using ultrasound. No central imaging was done. It was subsequently found on CXR coiled in right atrium
The possible causes & minimising this risk are considered
https://t.co/RDZbAdxabo
Our case of the month is published!
It describes use of pre-operative stents to help identify ureters during difficult sigmoid colectomy
Despite their use, one of the ureters was inadvertently cut
We discuss this case & include a systematic review ref
https://t.co/RDZbAdwClQ
Our case of the month has just been published
This one relates to wrong interpretation of an on-table cholangiogram causing signficant complications
Always good practice to check & double check findings, and STOP operating if there is any doubt.
https://t.co/RDZbAdwClQ
Our case of the month has just been published
For August we have not one but three cases with similar issues - retracted drains in the abdomen requiring surgery to remove them
Use of a safety pin would have prevented all three complications
https://t.co/RDZbAdwClQ
Our case of the month is a rare event occurring after laryngectomy & hemithyroidectomy for a tumour
The patient had a hypoglossal nerve palsy causing swallowing issues post op
Good operation notes were key to successfully defending this unexplained case
https://t.co/OTHBQaUXvv
Our case of the month is an incompletely removed appendix which caused issues 18 months later and led to litigation.
Good record keeping is so important as are operative images
If the appendix had been removed at the time, this would have been proved.
https://t.co/RDZbAdwClQ
Our case of the month is about removing a PEG tube
Highlights lots of learning points including communication, delegating without checking experience & other factors
No harm came to the patient as the trainee recognised his limitations & called for help
https://t.co/RDZbAdwClQ
⭐️ Project launch!! ⭐️
CROSS-CHECK: A multi-centre CROSS-sectional study and audit of surgical safety CHECKlist Modification
Sign-up now to be a local collaborator in the first national human factors trainee collaborative project.
Deadline 1st June 2025
https://t.co/ydON89XjOe
Our case of the month for April is unusual
During a long procedure a second segment of bowel was removed, but this was left inside the abdomen
Surgeon only realised while driving home.
A long case, limited breaks & other factors discussed
Read here
👇
https://t.co/RDZbAdwClQ
Human Factors in Healthcare Conference 6/10/25
REGISTRATION NOW OPEN
£70 (cost price) with limited free places for students (sign up quickly!)
6 CPD points
Should be a great day with amazing speakers, hot topics & a free paper session
Can't wait! 😀
https://t.co/vy9Ll3vcuq
Our case of the month for April is unusual
During a long procedure a second segment of bowel was removed, but this was left inside the abdomen
Surgeon only realised while driving home.
A long case, limited breaks & other factors discussed
Read here
👇
https://t.co/RDZbAdwClQ
Our March case of the month is really interesting.
As with so many errors, this was one multi-factorial, starting with an upset child
Despite completing a check list, an incision was placed in the wrong place due to a distracting site marking
See below
https://t.co/RDZbAdxabo
Our Case of the Month highlights how error can often be multifactorial
Here an elderly patient did not get an urgent CT scan as surgical team were awaiting blood results
Tragically, as a result of delays, the patient died
Read our findings & report
👇
https://t.co/RDZbAdwClQ
Congratulations to the winners! Dr Sunil Kumar donated 100 copies of the book he co-authored with Dr Toni Brunning: “The Power of Preparation for surgery”. @CPOC_news advertised & sent 10 lucky winners 10 books each for their staff/patient benefit. Sorry to 41 unlucky applicants.
Happy New Year from us all at CORESS
This month's case of the month is wrong side surgery
Please check out the link below to see how this can happen...
Lots of learning points
Here's to a safer 2025 for our patients!
https://t.co/RDZbAdxabo