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What to do when it happens – advice from a Senior Consultant

Here are some very wise words from a Consultant who has seen it all before!

  • Take a deep breath and step away from the table – obviously if safe to do so

  • Take another deep breath and tell someone senior and sensible in theatre there is a problem. Be cautious about just announcing in theatre, the patient may be awake, rumour control will have it out in the corridor before you can blink and by the time it comes back you will have removed the wrong hand and leg

  • Phone a friend or your boss. Preferably get them to come immediately to the theatre if on site but it not, un-scrub and spend 5 minutes or longer talking to them about your options

  • Get them to join you if feasible and complete case with them there – you will be pretty unsettled and do not want any more issues

  • Write a full operation note

  • Have a cup of tea (or a large quantity of chocolate!)

  • Consider cancelling the rest of the list

  • Debrief team in theatre – don’t forget they will be upset and will be called on by investigation

  • Write a full account immediately and email to yourself and friend +/- Clinical Director/Lead clinician

  • Fill in Datix

  • Contact your defence union

  • Phone your friend/mentor/someone who knows the operation and talk about it. Most complications have been done before...


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