‘Oops!’ Designing and implementing a novel peer-to-peer training session on learning from surgical mistakes

S Williams, A Stoneham, J Hardie, G Neal-Smith, F Guerreiro

University Hospital Southampton NHS trust

Mistakes in surgery are exceptionally common; they can harm surgeons as well as patients and are a major burden on healthcare systems in terms of wasted resources and the cost of litigation. Surgeons are not prone to seeking support for their mistakes and there are few forums available for them to discuss them with their peers.

We conducted an all-day peer-to-peer session aimed at Speciality Registrars in the Wessex region. It was organised by senior trainees and overseen by an experienced, recently retired NHS Consultant. There were guest speakers, including GP and professional whistle-blower Dr Phil Hammond, and trainees were encouraged to share their mistakes and dissect the learning points.

A pre-course survey showed that all ST3-ST8 trainees had experienced at least one and up to 10 “serious” mistakes in their careers to date. The commonest cited contributing factor was lack of familiarity with equipment. Seven registrars presented specific cases which ranged from technical equipment issues to misplaced implants and wrong site surgery.

Course feedback was overwhelmingly positive and there was a strong feeling that this should be incorporated into the regular Registrar teaching syllabus regionally, if not nationally. Participants came away comforted that they were not alone in their mistakes, more aware of how to spot and avoid errors, and better informed as to what to do when one occurs.