Surgeon gives patient a vasectomy by mistakeBMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g3180 (Published 08 May 2014) Cite this as: BMJ 2014;348:g3180
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Surgeon Gives Patient Vasectomy by Mistake BMJ 2014;348 g3180
While not excusing the mistake, it is a fact that humans and the systems that they develop will always be fallible. To minimise the chances of error it is essential that a service and the people who work within it can learn from mistakes and the precursor events and near misses that invariably precede them. I have no doubt that a detailed investigation is being undertaken within the Liverpool Royal Infirmary. Nor that the findings will escalate through the serried ranks of provider, commissioners, NHS Boards and certainly the civil litigation system. But where can surgeons in hospitals throughout the UK, who are leading the delivery of services, easily find and profit now from the learning contained within this and other ‘Never’ events?
The surgical profession through its own voluntary reporting and publication system (www. coress.org.uk) provides a platform through which surgeons can share learning from less serious incidents and near misses but although valuable, this cannot on its own address the need for more widespread publication of the learning contained in serious medical accidents. The Royal College of Surgeons published in March of this year a significant report, ‘Building a Culture of Candour’. In this it makes clear that a lack of general access to the details of ‘Never’ events and Serious Untoward Incidents is holding back the wider dispersal of learning from these mishaps and that it is the duty of Trusts to address a serious deficiency in closing this vital section of the learning cycle. Until then all of us whether in practice or positions of leadership remain vulnerable to making similar mistakes and this is simply not good enough.
(Trustee, CORESS; Confidential Reporting System in Surgery)
Competing interests: No competing interests