CORESS

Confidential Reporting System in Surgery.
Independent charity run by surgeons sharing lessons to improve safety. Many errors are preventable.

[Peter Brennan @BrennanSurgeon]

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

[Peter Brennan @BrennanSurgeon]

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

[CORESS @CORESS5]

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

[CORESS @CORESS5]

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

[CORESS @CORESS5]

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

[CORESS @CORESS5]

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

[CORESS @CORESS5]

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

[CORESS @CORESS5]

@BrennanSurgeon The ball costs £1

[CORESS @CORESS5]

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

[CORESS @CORESS5]

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

[CORESS @CORESS5]

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

[Human Factors in Surgery Network @HumanFactorsSN]

⭐️ 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

[CORESS @CORESS5]

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

[Peter Brennan @BrennanSurgeon]

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

[CORESS @CORESS5]

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

[CORESS @CORESS5]

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

[CORESS @CORESS5]

Do you remember when you joined X? I do! #MyXAnniversary

[CORESS @CORESS5]

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

[Prof Scarlett McNally @scarlettmcnally]

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.

[CORESS @CORESS5]

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