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Reporting Near Misses - Untoward Incident or Known Complication?

The benefits of reporting near misses are surely beyond dispute. Each close shave is a learning opportunity which should be shared with others. Does every doctor need to experience problems first hand and patients endure possible harm in order to gain a high level? 

I have recently heard of an incident in maxilla-facial surgery which has disquieted me. A senior consultant decided to perform two lengthy operations in one day and incur a significant overrun to the detriment of the theatre teams. It had been possible to ask a fellow senior surgeon to take on one case and indeed such an offer had been made. The offer was impolitely refused.
The second procedure was commenced at 4 pm and involved a neck dissection. Unfortunately a small tear was made in the lower end of the jugular vein where it joined the subclavian vein. The anatomy was non-normal in that the vein was above the clavicle rather than under.
 
There was considerable haemorrhage which was not controllable. Vascular surgeons were called and the vessel was approached from the anterior chest wall, but were unable to control the bleeding. Eventually orthopaedic surgeons were called to divide the clavicle and the tear was over-sewed. The patient lost 18 units of blood and the cell-saver was used successfully to replace lost blood. The anaesthetist performed very well in difficult circumstances.
 
What could be learned?

The surgeon did not consider this a reportable incident and indeed was most vociferous in wishing it not to be reported. One must ask why? Does it indicate fear of the local culture? Or is it something more ego-driven?
 
What would you consider the professional response?
 
Surely if this is a recognised non-normal anatomical situation it should be shared to help junior doctors learn to avoid it happening to them?
 
How can we make it ‘safe’ to report near-misses and move the whole culture closer to the aviation model where incident reporting is actively encouraged? 

We specialise in training for debriefing to learn. Blame serves little useful purpose unless people are wilfully ignoring rules and due process.
 
Training utilises the greatest resource – a team member who may have made a mistake despite trying their best not to. What a resource to help the whole organisation learn! Shame to waste it.

Human Factors - common sense made conscious
Lighting the Blue Touchpaper
 

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Saturday, 07 December 2019