53 Photos and videos
CORESS retweeted
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!
👇
doi.org/10.1308/rcsbull.2026…
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CORESS retweeted
Mar 16
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
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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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…
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CORESS retweeted
15 Apr 2025
⭐️ 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/cr…
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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…
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CORESS retweeted
6 Apr 2025
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/20…
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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…
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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…
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CORESS retweeted
19 Jan 2025
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.
ALT Picture of book cover, more written information about book contents (preparing for surgery, such as healthy food) and a sticker inside each book showing it was a personal donation from one of the authors.
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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…
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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…
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