CORESS

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 coress.org.uk/case-of-the-mo…

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 coress.org.uk/case-of-the-mo…

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 coress.org.uk/case-of-the-mo…

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. coress.org.uk/case-of-the-mo…

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 coress.org.uk/case-of-the-mo…

@BrennanSurgeon The ball costs £1

A bat and ball costs £11.00 The bat costs £10 more than the ball. So how much does the ball cost? An example of how quick thinking can lead to potential error..

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 coress.org.uk/case-of-the-mo…

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. coress.org.uk/case-of-the-mo…

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 coress.org.uk/case-of-the-mo…

⭐️ 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 humanfactorsinsurgery.net/cross-check-pr…

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 👇 coress.org.uk/case-of-the-mo…

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! 😀 humanfactorsinsurgery.net/2025-conferenc…

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 coress.org.uk/case-of-the-mo…

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

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 👇 coress.org.uk/case-of-the-mo…

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! coress.org.uk/case-of-the-mo…

Poor communication is a significant cause of medical error In 2022-3 it was commonest cause of never events such as wrong site surgery, implants or protheses, and retained instruments/swabs Our latest case of the month highlights poor communication coress.org.uk/case-of-the-mo…