CORESS is an independent charity, which aims to promote safety in surgical practice in the NHS and the private sector. CORESS receives confidential incident reports from surgeons and theatre staff. These reports are analysed by the Advisory Board, who make comments and extract lessons to be learned. Aiming to educate, and avoid blame, CORESS calls on surgeons to recognise a near miss or adverse event, react by taking action to stop it happening and then report the incident to CORESS so that the lessons can be published.
Every month CORESS highlight's one of the cases reported for you to consider the issues raised and read the experts comments.
The focus of CORESS is on detecting and learning from no-harm, near-miss and low harm events encountered during routine surgical practice. The programme collects reports of such events, analyses them and disseminates the learning contained within them to a wide surgical audience and other agencies involved in Patient Safety matters. These events are known collectively as ‘Accident Precursor Events’ or simply ‘Precursors’.
See previous reports below.
Summer 2021 - Unrecognised limb ischemia following trauma, differences of opinion in management for tongue laceration, lack of communication in patient discharge, consequences of service disruption during the COVID-19 Pandemic, systems and communications errors leading to orthopaedic Never Event, too slick by half.
Winter 2020 - Missed pulmonary embolism, gastrectomy kit miscommunication, leaking gastrostomy, fatal pulmonary embolus after renal cancer surgery, ureteric injury, PICC line misplacement, CVP line causing haemothorax.
Summer 2020 - Thoracic outlet surgery complications, missed breast tumour in pooled case, abscess confusion, injection error, fall from grace, atypical thromboses.
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