CORESS

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…