“Our mistakes reflect our experience…”
Oscar Wilde
Recently I have taken up a role helping to audit peri-operative deaths in my local jurisdiction . To be involved in such work is important to me. For many people such an audit is seen primarily as a means of detecting rogue surgeons and their inhuman acts. Rogue surgeons are popular in podcasts, movies and TV series, but thankfully almost never encountered in the real world. Peri-operative mortality audits do act as a canary in the coal mine for such cases, but actually have a more important role supporting good healthcare and good healthcare decisions. What I see is human frailty, the extremes of disease and trauma, complex systems, ambiguous options, social pressures and outright misfortune. Patients and their families are central to this work, but there are impacts to all involved. A 2024 publication in JAMA revealed that 80% of US Surgeons have had a recent adverse event. Following this over 80% reported intrusive rumination. Two thirds were avoiding similar future situations and procedures. One third were considering leaving healthcare. Nearly all reported issues with support and isolation. #castingthefirststone #letsmakelemomade
Pen Paint and Scalpel 