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Showing results for tags 'Surgeon'.
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Content Article
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Content ArticleIn an editorial for the World Journal of Surgery, Gogalniceanu et al. describe five concepts that can help surgical institutions adapt and create a crisis control plan in dynamic circumstances: Command Communications Capacity and resource management Contingency planning Clinical knowledge
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News Article
Cosmetic surgeon is suspended for series of failures in patient care
Patient Safety Learning posted a news article in News
A cosmetic surgeon has been suspended from the UK medical register for nine months for failures in obtaining informed consent, pressuring a patient into surgery by offering a discount, and laughing when passing on a patient’s complaint of sexual assault by another doctor. Ashish Dutta is the nominated member for the European Society of Aesthetic Surgery on the European Commission for Standardisation of Aesthetic Surgery Services. He is also an examiner for the World Board of Cosmetic Surgery. Read full story (paywalled) Source: BMJ, 27 November 2019 -
News Article
Women needlessly having their appendix out in almost one in three cases
Patient Safety Learning posted a news article in News
Women are having their appendixes removed wrongly in nearly a third of cases, British research suggests. Researchers said too many female patients were being put under the knife when they should have undergone investigations for period pain, ovarian cysts or urinary tract infections. They said the study, which compared practices in 154 UK hospitals with those of 120 in Europe, suggests that Britain may have the highest rate of needless appendectomies in the world. Surgeons said they were particularly concerned by the high rates among women, with 28% of operations found to be unnecessary. They said the NHS was too quick to book patients in for surgery, when further scans and investigations should have been ordered. Researchers warned that such operations put patients at risk of complications, as well as fuelling NHS costs. Read full story Source: The Telegraph, 4 December 2019 -
News Article
Royal Cornwall Hospital deploys AI tool for secure surgical videos
Patient Safety Learning posted a news article in News
Royal Cornwall Hospital has deployed an artificial intelligence (AI) tool that allows clinicians to view case videos safely and securely. Touch Surgery Enterprise enables automatic processing and viewing of surgical videos for clinicians and their teams without compromising sensitive patient data. These videos can be accessed via mobile app or web shortly after the operation to encourage self-reflection, peer review and improve preoperative preparation. James Clark, consultant upper gastrointestinal and bariatric surgeon at the trust, said: “Having seamless access to my surgical videos has had an immense impact on my practice both in terms of promoting patient safety and for educating the next generation of surgeons." Read full story Source: Digital Health, 28 November 2019 -
News Article
Dr Michael Watt: Suspended neurologist offers 'sympathy' to patients
Patient Safety Learning posted a news article in News
Suspended Belfast neurologist Michael Watt has offered his "sincere sympathy" to those affected by Northern Ireland's biggest patient recall. Dr Michael Watt worked at the Royal Victoria Hospital as a neurologist diagnosing conditions like epilepsy and Parkinson's Disease. He was suspended after 3,000 patients were given recall appointments last year. Dr Watt said he recognised the "distress these events have caused". On Tuesday, a BBC Spotlight investigation found that he had carried out hundreds of unnecessary procedures on patients. The programme also obtained details of a Department of Health report, as yet unpublished, that said one-in-five patients of the consultant neurologist were misdiagnosed. Read full story Source: BBC News, 22 November 2019 -
News Article
Patient died after 'transplant surgeon error'
Patient Safety Learning posted a news article in News
A transplant patient died after a surgeon failed to disclose he had spilt stomach contents on organs which went on to be used in NHS operations. The 36-year-old died of an aneurysm caused directly by infection from a donated liver, while two other patients became ill from transplants. The incident took place in 2015 but only came to light when one of the sick patients attended a hospital in Wales. It had involved a surgeon from Oxford University NHS Foundation Trust. Several organs became infected with Candida albicans, a fungal infection, after the surgeon cut the stomach in a donor while retrieving organs, spilling the contents over other organs. The surgeon did not tell anyone as he should have done and the organs were transplanted into three patients. The patient, who did not want to be named, said: "What angers me to this day is that fact that the surgeon who removed the organs from the donor wasn't honest. It was only when people who received the organs became unwell that the truth was told." Read full story Source: BBC News, 21 November 2019 -
News ArticleThe United States Surgeon General Dr. Vivek Murthy issued a new Surgeon General’s Advisory highlighting the urgent need to address the health worker burnout crisis across the country. Health workers, including physicians, nurses, community and public health workers, nurse aides, among others, have long faced systemic challenges in the health care system even before the COVID-19 pandemic, leading to crisis levels of burnout. The pandemic further exacerbated burnout for health workers, with many risking and sacrificing their own lives in the service of others while responding to a public health crisis. Promoting the mental health and well-being of our nation’s frontline health workers is a priority for the Biden-Harris Administration and a core objective of President Biden’s national mental health strategy, within his Unity Agenda. The Surgeon General’s Advisory Addressing Health Worker Burnout lays out recommendations that the whole-of-society can take to address the factors underpinning burnout, improve health worker well-being, and strengthen the nation’s public health infrastructure. “At the height of the COVID-19 pandemic, and time and time again since, we’ve turned to our health workers to keep us safe, to comfort us, and to help us heal,” said Secretary of Health and Human Services Xavier Becerra. “We owe all health workers – from doctors to hospital custodial staff – an enormous debt. And as we can clearly see and hear throughout this Surgeon General’s Advisory, they’re telling us what our gratitude needs to look like: real support and systemic change that allows them to continue serving to the best of their abilities. I’m grateful to Surgeon General Murthy for amplifying their voices today. As the Secretary of Health and Human Services, I am working across the department and the U.S. government at-large to use available authorities and resources to provide direct help to alleviate this crisis.” “The nation’s health depends on the well-being of our health workforce. Confronting the long-standing drivers of burnout among our health workers must be a top national priority,” said Surgeon General Vivek Murthy. “COVID-19 has been a uniquely traumatic experience for the health workforce and for their families, pushing them past their breaking point. Now, we owe them a debt of gratitude and action. And if we fail to act, we will place our nation’s health at risk. This Surgeon General’s Advisory outlines how we can all help heal those who have sacrificed so much to help us heal.” Read full story Source: HHS, 23 May 2022
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News Article
Breast surgeon's victim wants faster improvements
Patient Safety Learning posted a news article in News
Victims of breast surgeon Ian Paterson said independent inquiry improvements are not being implemented fast enough. Paterson was jailed in 2017 after he was found to have carried out needless operations on patients across Birmingham and Solihull. The 2020 report's recommendations include the recall of his 11,000 patients to assess their treatment. The Department of Health and Social Care (DHSC) said it is working to stop future patients facing similar harm. On Sunday, ITV screened a documentary 'Bodies of Evidence: The Butcher Surgeon' which featured victim and campaigner Debbie Douglas, who was instrumental in getting the inquiry established. She said the government needs "to put pace behind" the work to implement the 15 recommendations it made. "It is important those recommendations are embedded in legislation, it is important there is governance over those recommendations to stop another Paterson, it is important that there is a proper consent procedure," she said. The recommendations called for consultants to write directly to patients to explain proposed surgical treatment as standard practice, a public register to detail which types of operations surgeons are able to perform and for patients to be given time to reflect on their diagnosis and treatment options before they are asked to consent to surgery. Read full story Source: BBC News, 14 June 2022 -
News ArticleTwo talented physicians, a patient who sacrificed his life and a selfless receptionist were the four people killed on 1 June 1 a shooting inside a medical office building on the Saint Francis Health System campus in Tulsa, Oklahoma. Police in Tulsa say the gunman, Michael Louis, had gone to the hospital for back surgery 19 May and was treated by Dr Preston Phillips. Louis was discharged from the hospital 24 May and subsequently called Dr Phillips' office several times complaining of pain and seeking additional treatment. The surgeon saw Mr. Louis on 31 May for more treatment, police said. On 1 June, Mr Louis called Dr Phillips' office again complaining about pain and seeking additional care. Mr Louis purchased an AR-15-style rifle that afternoon, just hours before the shooting, police said. Dr Phillips was killed in the shooting and was the gunman's primary target, police said. "He blamed Dr Phillips for the ongoing pain following surgery," Tulsa Police Chief Wendell Franklin said at a news conference. Read full story Source: Becker's Hospital Review, 2 June 2022
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News ArticleA Bristol woman says her life has 'never been the same' since receiving unnecessary operations on her bowel more than ten years ago. Following a recent review, Mandy Giltrow is one of more than 200 patients who received a mesh bowel procedure - which she says may not have been needed. The operations were all conducted by surgeon Tony Dixon who has been sacked by the North Bristol NHS Trust. Mandy Giltrow underwent a mesh bowel procedure which was performed by Mr Dixon at Frenchay Hospital in April 2011. Following the surgery her symptoms continued. Following follow up appointments Mandy, a mum-of-four, underwent a further procedure in April 2013. Mr Dixon carried out a further operation in October 2014 at Spire Bristol to replace mesh. However Mandy, who is 49 and lives in Staple Hill, continues to suffer issues including stomach and bowel pain as well as recurrent water infections. She also has a hernia near her surgery scars. North Bristol NHS Trust has since admitted liability. Mandy told ITV West Country: "I got anxiety for all the different operations I had and then I physically could not do anything. I was stuck for three months in a bubble." "I couldn't go out, I couldn't do anything with my children not even take them to school." Mandy says her mental health was badly affected by the operations leading to a nervous breakdown and agoraphobia, meaning she could not lead the house. "You have an operation. It doesn't resolve the original problem and now you have another problem which is twice as bad." Read full story Source: ITV, 30 May 2022
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News Article
Bristol surgeon ‘harmed’ 203 women with unnecessary operations
Patient Safety Learning posted a news article in News
More than 200 women were harmed when a rogue surgeon carried out operations on them unnecessarily, an NHS inquiry has found. Some of the women were left with life-changing physical problems or unable to work, while many also suffered trauma and serious psychological harm as a result. Overall, 203 women on whom Anthony Dixon performed procedures between 2007 and 2017 came to harm, according to a review by the North Bristol NHS trust (NBT). Dixon, who for years was Britain’s most influential pelvic surgeon, worked for both the trust and the private Spire hospital in the city. In 2017, NBT launched a review of Dixon’s performance and suspended him after dozens of women he had performed procedures on complained that they had experienced appalling consequences, including unmanageable pain and incontinence. The Guardian revealed in late 2017 that 100 women were suing him for medical negligence. Some cases have since been settled, but dozens are ongoing. NBT sacked Dixon in 2019 and he is currently banned from practising in the UK. During the review, 378 women were recalled and asked to set out their dealings with Dixon. All had undergone a procedure called laparoscopic ventral mesh rectopexy (LVMR), in which plastic mesh is inserted to repair weakened tissue in the pelvic floor. In papers presented to NBT’s board on Thursday, board members were told that the inquiry had concluded. “The trust has notified 203 NHS patients that, although their LVMR operation was carried out satisfactorily, they should have been offered alternative treatments before proceeding to surgery. We have defined these patients as suffering ‘harm’ as a result,” it said. Read full story Source: The Guardian, 26 May 2022 -
News ArticleHeart surgery patients in London have died “unnecessarily” and faced increased risk of death as botched NHS investigations into dozens of deaths reduced a hospital’s ability to treat people, a coroner has warned. “Unnecessary” patient deaths have occurred as a result of heart surgery at St George’s University Hospital Trust being restricted and emergencies diverted to other “over stretched” hospitals, following investigations by national NHS bodies. The warning that deaths have occurred and may occur in the future, comes following the conclusion of a series of inquest hearings in March, during which it was found the NHS’ wrongly blamed a team of cardiac surgeons for the deaths of dozens of patients. Coroner Fiona Wilcox, in a report published on Wednesday, has now said the “inadequate” NHS led investigations, which criticised the care of 67 patients, led to people being put increased risk of death. The NHS’ investigations into the deaths of 67 patients ruled there were “shortcomings” in care. It led to complex operations being diverted elsewhere and doctors being referred to the General Medical Council. Two doctors have sinced been exonerated following GMC hearings. According to the coroner’s findings, capacity within cardiac surgery at the unit is down by 60% and staff are becoming “deskilled.” Read full story Source: The Independent, 11 May 2022
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News Article
Coroner concerned with Barts NHS trust after woman 'unlawfully killed'
Patient Safety Learning posted a news article in News
Barts Health NHS Trust has been told to take action to prevent future deaths after an elderly woman was unlawfully killed at one of its hospitals. East London acting senior coroner Graeme Irvine sent a report to the trust in which he raised concerns over the death of 78-year-old Surekha Shivalkar in 2018. The report follows an inquest into Mrs Shivalkar's death, which reached a narrative conclusion incorporating a finding of unlawful killing. A Barts spokesperson said the trust had made a number of changes after carrying out an investigation. Mrs Shivalkar underwent hip replacement revision surgery at Newham Hospital on September 28, 2018 in a procedure estimated to last between four and five hours, the coroner wrote. She had a number of serious conditions, including ischaemic heart disease, osteoporosis and chronic obstructive pulmonary disorder. But Mr Irvine said an inaccurate risk of death of less than 5% was given, as no formal risk assessment tool was used. The surgery took longer than seven and a half hours, during which time Mr Irvine said Mrs Shivalkar sustained a "prolonged and dangerous" period of hypotension, or low blood pressure. He said the anaesthetist failed to communicate this to the surgical team and agreed to prolong surgery at the six hour point. Mr Irvine said: "Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient." Read full story Source: Newham Recorder, 17 January 2022 -
News Article
Liver-branding transplant surgeon struck off medical register
Patient Safety Learning posted a news article in News
A surgeon who burned his initials on to the livers of two patients during transplant surgery has been struck off the medical register. Simon Bramhall, 57, admitted using an argon beam – used to stop livers bleeding during operations and to highlight an area to be worked on – to sign “SB” into his patients’ organs in 2013 while working at Birmingham’s Queen Elizabeth hospital. On Tuesday, a review by the Medical Practitioners Tribunal Service (MPTS) concluded Bramhall’s actions were “borne out of a degree of professional arrogance” and that they “undermined” public trust in the medical profession. Bramhall, of Tarrington, Herefordshire, was first suspended from his post as a consultant surgeon in 2013 after another surgeon spotted the initials during follow-up surgery on one of his patients. A photograph of the 4cm-high branding was taken on a mobile phone. During his sentencing hearing in 2018, Bramhall was told one of the victims suffered serious psychological harm as a result of the branding. The surgeon later told police he branded the organs to relieve operating theatre tensions following difficult and long transplant operations. Read full story Source: The Guardian, 11 January 2022 -
News Article
Women 32% more likely to die after operation by male surgeon, study reveals
Patient Safety Learning posted a news article in News
Women who are operated on by a male surgeon are much more likely to die, experience complications and be readmitted to hospital than when a woman performs the procedure, research reveals. Women are 15% more liable to suffer a bad outcome, and 32% more likely to die, when a man rather than a woman carries out the surgery, according to a study of 1.3 million patients. The findings have sparked a debate about the fact that surgery in the UK remains a hugely male-dominated area of medicine and claims that “implicit sex biases” among male surgeons may help explain why women are at such greater risk when they have an operation. “In our 1.3 million patient sample involving nearly 3,000 surgeons we found that female patients treated by male surgeons had 15% greater odds of worse outcomes than female patients treated by female surgeons,” said Dr Angela Jerath, an associate professor and clinical epidemiologist at the University of Toronto in Canada and a co-author of the findings. “This result has real-world medical consequences for female patients and manifests itself in more complications, readmissions to hospital and death for females compared with males. “We have demonstrated in our paper that we are failing some female patients and that some are unnecessarily falling through the cracks with adverse, and sometimes fatal, consequences.” Read full story Source: The Guardian, 4 January 2022 -
News Article
Government commits to public repository of consultant details “in principle”
Patient Safety Learning posted a news article in News
The government has committed “in principle” to creating a public repository of consultants’ practice details that sets out their practising privileges and key performance data, including how many times they have performed a particular procedure and how recently. The commitment was part of the response to an independent national inquiry, launched in 2017, following the malpractice of rogue surgeon Ian Paterson. Now serving a 20 year prison sentence, Paterson had undertaken numerous unnecessary breast operations in both private and NHS practice, causing harm to hundreds of patients. The inquiry, published February 2020, found that Paterson was able to harm patients over more than decade because of the “dysfunctional” healthcare system. It outlined 17 recommendations for the government to respond to, mainly focusing on improving oversight and governance, as well as ensuring greater scrutiny of private providers. At the time, some saw the report as a missed opportunity to tackle the systemic patient safety risks of the private hospital business model, such as financial incentives which can lead to overtreatment. Read full story Source: BMJ, 17 December 2021 -
News Article
Surgery 'may have played role in woman's death'
Patient Safety Learning posted a news article in News
An inquest into whether a pioneering surgery technique played any role in a Gloucestershire woman's death has opened. Jacqui Kingston, from Marshfield, died on 16 March 2020 after having mesh fitted for a prolapsed bowel at Southmead Hospital in Bristol. On Monday an inquest opened at Avon Coroner's Court examining whether the surgery performed by colorectal surgeon Tony Dixon contributed to her death. It is due to run until Thursday. Pathologist Edward Sheffield told the hearing that the use of the mesh for a prolapsed bowel - which was fitted in 2016 - may have contributed to her death. The inquest heard that Mrs Kingston was a fragile patient with many underlying health conditions who developed complications. Mr Dixon was dismissed by the North Bristol NHS Trust in 2019 after dozens of his patients were told they should have been offered alternative treatment first. Read full story Source: BBC News, 13 December 2021 -
News Article
Mesh surgeon fails in bid to stop legal action against trust being made public
Patient Safety Learning posted a news article in News
A leading colorectal surgeon whose former employer, North Bristol NHS Trust, faces negligence claims from dozens of his ex-patients has failed in his bid to keep legal action he is taking against the trust a secret. A review by the trust found that 203 women on whom the surgeon Tony Dixon performed pelvic mesh procedures between 2007 and 2017 came to harm. The trust faces legal claims from many of them. Trust board members were told in May that the trust had notified the 203 women that “although their laparoscopic ventral mesh rectopexy operation was carried out satisfactorily, they should have been offered alternative treatments before proceeding to surgery,” and that those patients were defined as suffering “harm.” Dixon sued the trust in the High Court to try to stop it releasing two documents to solicitors acting for ex-patients, as part of the disclosure process in litigation. Read full story (paywalled) Source: BMJ, 27 July 2022 -
News Article
Surgeon branded bully faces review after patient, 17, dies
Patient Safety Learning posted a news article in News
Catherine O’Connor, who was born with spina bifida and used a wheelchair all her life, was looking forward to the surgery to fix her twisted spine. Tragically, after a catastrophic loss of blood, she died on the operating table at Salford Royal Hospital in Manchester. She died in February 2007 but only now has an NHS-commissioned report concluded the “unacceptable and unjustifiable” actions of her surgeon, John Bradley Williamson, “directly contributed” to her death. Williamson pressed on with the surgery despite being explicitly told he needed a second consultant surgeon. Her case is one of more than a hundred of Williamson’s being reviewed by Salford Royal Hospital amid allegations by whistleblowers of a cover-up by managers and a “toxic culture” within his surgery team. An internal list produced by concerned clinicians as long ago as 2014 describes some of Williamson’s patients being left paralysed or in severe pain as a result of misplaced spinal screws and others being rushed back to theatre for life-saving surgery. Separately, leaked minutes of a meeting between staff and the hospital’s new chief executive in December 2021 described a “snapshot” of five of Williamson’s patients which “clearly identified significant areas of clinical care, avoidable harm and avoidable death”. They added: “Concerns around Mr Williamson continue to be raised and remain unaddressed.” Read full story (paywalled) Source: The Times, 17 July 2022 -
News Article
Sweden: surgeon convicted of bodily harm over synthetic trachea transplant
Patient Safety Learning posted a news article in News
A Swedish court has found an Italian surgeon, once hailed for pioneering windpipe surgery, guilty of causing bodily harm to a patient, but cleared him of assault charges. Paolo Macchiarini won praise in 2011 after claiming to have performed the world’s first synthetic trachea transplants using stem cells while he was a surgeon at Stockholm’s Karolinska University hospital. The experimental procedure was hailed as a breakthrough in regenerative medicine. But allegations soon emerged that the procedure had been carried out on at least one person who had not been critically ill at the time of the surgery. During the May trial, held in the Solna district court, prosecutors argued that the surgeries on three patients in Sweden constituted assault, or alternatively bodily harm due to negligence, as Macchiarini disregarded “science and proven experience”. The district court agreed with the prosecutors, but cleared Macchiarini on two counts as the patients’ health was in such a dire state. “Given the patients’ condition, the district court finds that the procedures on the first two patients were justifiable,” it said in a statement. However, in the third patient, the court found him guilty of "causing bodily harm". "At the time of the third procedure, the experience from the first procedures was such that the surgeon should have refrained from letting yet another patient go through the operation", the court said. Macchiarini was handed a suspended sentence. Read full story Source: The Guardian, 16 June 2022 -
Content ArticleKey recommendations For Commissioners 1. Investment should be provided to: (a) establish prehabilitation services; (b) enable integrated Care Systems (England), Health Boards (Wales), Regional Health Boards (Scotland) and Health and Social Care Trusts (NI); and (c) expand perioperative services For NHS X 2. Ongoing work to bridge the Primary - secondary care interface should be accelerated. For primary care providers, surgeons, anaesthetists and multidisciplinary teams 3. Shared Decision Making (SDM) should be embedded throughout perioperative pathways. beginning at the earliest point where surgery is contemplated, and involving discussion between patient, surgeon, and the broader multidisciplinary team. 4. At the earliest possible point in the surgical pathway (e.g. at the point of referral from primary care, or at the first review in surgical clinic) patients should complete a screening self-assessment health questionnaire, to help shared decision making, risk prediction and optimisation. 5. Referrals from primary care to surgeons and from surgeons to Preoperative Assessment (POA) Services should detail significant medical comorbidities using a “fitness for surgery” process to enable early optimisation and review. For preoperative assessment services 6. Every patient requiring surgery and/or anaesthesia/anaesthesia-led sedation should undergo formal preoperative assessment before the day of admission. 7. Patients should be assessed for impact of comorbid conditions on functional capacity, perioperative pathways and surgical outcome. 8. Patients should be screened for cognitive impairment, psychological distress and risk of malnutrition using validated tools. For surgeons, anaesthetists and perioperative multidisciplinary teams 9. All patients being considered for surgical intervention should have their individualised risk assessed using objective measures, combined with senior, experienced clinical judgement. 10. Where possible, surgery should be avoided for 7 weeks after COVID-19 infection, or until symptoms have resolved, to avoid the higher risk of postoperative complications and death associated with earlier surgery. 11. All patients who are being considered for a surgical intervention should be screened for reduced functional capacity/physical fitness using a validated tool such as the Duke Activity Status Index (DASI). 12. All patients should be advised that improving fitness before surgery reduces risk of complications after surgery, and improves length of hospital stay, speed of recovery and quality of life. All healthcare professionals should be competent to deliver universal exercise advice to all patients following UK CMO (WHO) guidance. 13. All patients considered for a major or inpatient elective surgical intervention should be invited to attend a group ‘surgery school’, which may be in-person, via remote access or hybrid. 14. All surgical / perioperative services should have a system for active clinical surveillance of patients on waiting lists, particularly those who have been waiting for longer than 3 months. 15. Prompt preoperative assessment and optimisation, supported by agreed local pathways based on national recommendations, should be prioritised in emergency surgery. This will ensure efficient and safe care which will benefit best use of hospital resources, creating more capacity for both emergency and elective work.
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Content ArticleIn this report, the Coroner states their concerns as follows: No formal risk assessment tool was adopted to assess preoperative risk prior to Mrs Shivalkar's total hip replacement revision surgery. Despite policy changes at Barts Heath NHS Trust since 2018, there remains no requirement to utilise such a tool. Poor communication between the orthopaedic surgical team and the anaesthetist during surgery led to a collective failure to identify a critically ill patient. General and non-specific questions regarding the patient's welfare passed between the two teams but no targeted questions requiring clear factual responses were asked. Had such questions been put, a different outcome may have arisen. The Senior Consultant surgeon left the surgery prior to its conclusion, lengthening the procedure. The Consultant did not effectively communicate his reasons for leaving the surgery to the other members of the surgical team, neither did the surgical notes refer to his early departure. The Consultants statement to the court did not indicate that he had left the surgery before its conclusion. No system was in place to; assess whether a decision to leave surgery was appropriate, or to effectively monitor when a surgeon leaves theatre. This report was sent to the Royal London Hospital, Department of Health and Social Care, Royal College of Surgeons and Royal College of Anaesthetists.
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Content ArticleThe College’ s guidance is a practical guide for setting up, running and participating in high quality surgical M&M meetings. Preparation and organisation of meetings to ensure they are well-supported and attended. Effective chairing of meetings. Types of behaviours that participants should display to ensure discussions are held in an open and inclusive atmosphere. Presentation and discussion of cases Ensuring that actions arising from meetings are sucessfully completed and that lessons are learned and implemented. Read the guidance here. The following templates are also available to assist teams in running a surgical M&M meeting: A sample meeting agenda A checklist for the M&M coordinator A sample format for case presentation A discussion summary recording form A reflection log for the individual surgeon
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