Learning the lessons from problems, mistakes and near-misses is essential to the development of a high-quality service. It is important to have a system which disseminates learning points to the relevant professionals. Reporting systems originated in the airline industry: their programme for Confidential Human Factors Incident RePorting (CHIRP) had been very successful in passing on ‘lessons from problems’, and thereby improving safety. Since 2005, a similar system was set up by the Association of Surgeons of Great Britain and Ireland, called the Confidential Reporting System for Surgery (CORESS). The CORESS system now encompasses all the surgical specialties in UK and Irish practice and the four surgical Royal Colleges. In the summer of 2013, the RCOphth entered a formal agreement to join CORESS.
The purposes of CORESS may be summarized:
- To extract the lessons from mistakes, mishaps and near-miss events.
- To disseminate that learning in the most effective manner to those who are best placed to use that information in the interests of patient safety.
- To place particular emphasis on the importance of Human Factors in surgical practice.
An important mission statement, which marks out the differences between the modus operandi of CORESS and other NHS incident reporting systems is:
“To feedback widely to the surgical community and elsewhere, the learning contained within confidential reports of surgical accidents, errors, mishaps and near-miss events in a manner which is effective, but preserves the anonymity of the reporter and his/her institution of origin.”
The mechanism of feedback for ophthalmologists will be mainly via College News, carrying ‘learning points’ of interest to ophthalmologists. Some of these will be specific to ophthalmic surgery, whereas others might be from other surgical specialties if they illustrate a general point. All published cases will also appear on the CORESS website, www.coress.org.uk, and on the College website.
Ophthalmologists are encouraged to report adverse events to CORESS, via the website www.coress.org.uk On-line reporting is quick and simple, and reporters can be reassured that all reports will be anonymised and ‘disidentified’. Reporting a problem (and the resultant learning points) will assist your colleagues, and you will get an acknowledgement which can be added to your Revalidation folder. Perhaps most importantly, the patient who suffered the problem can be reassured that ‘I’ve reported this problem to the other eye doctors in the whole country, so hopefully it won’t happen again’.
Most ophthalmologists will be able to think of a case which illustrates a learning point for colleagues. We hope to publish the first ophthalmology CORESS report in spring 2014, so please do visit www.coress.org.uk to share your cases. We must emphasise that reporting to CORESS does not replace the requirement to report incidents via local/national patient safety reporting requirements.