A trainee experiences a dilemma when the consultant assigned to supervise him is our of their own depth...
How did I feel when I was asked to present my worst surgical mistake?!
Horrified, haunted, humiliated!
I was an ST4 Orthopaedic trainee. A patient in their mid-50s presented with persistent pain and was listed for revision from a Unicompartmental Knee Replacement (UKR) to a Total Knee Replacement (TKR). Throughout the case there were several significant issues including poor pre-operative planning, technical errors, communication difficulties between members of the surgical team, lack of familiarity with kit and duty of candour with the patient following surgery.
What I learnt about knee replacements... and myself
After presenting the case, we were able to reflect as a group on the many “system errors” that led up to that operation. We debated what we could have changed to affect the outcome and how each of us would have responded if placed in that situation.
"Open discussion of our errors helps raise awareness, encourage debate and promote patient safety"
What I would do differently
As surgeons it is inevitable that we will make mistakes in both our training and consultant practice. Open discussion of our errors helps raise awareness, encourage debate and promote patient safety.
Be sure to read about our other case reports in the Error Log
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