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‘NOTHING stands out so conspicuously, or remains so firmly fixed in our memory, as something in which we have blundered.’ Cicero, 105-43 BC.
It is an uncomfortable fact of medical and veterinary practice that surgical complications occur. Complications can arise due to either error or to ‘bad luck’. The first is relatively easy to define, the second less so. ‘Bad luck’ could represent just that or in some instances may be due to an unidentified error. While we can do little to prevent genuine ‘bad luck’ we are obliged to try to reduce known errors and to try to identify and reduce unknown errors.
Over recent years there has been an increasing focus in the medical profession on reporting and addressing this problem. To this end the World Health Organization (WHO) has established the ‘Safe Surgery Saves Lives’ campaign, which is an initiative designed to address the safety of surgical care (more information can be found at www.who.int/patientsafety/safesurgery/en/). American surgeon, author and public health researcher Atul Gawande, lead adviser for the campaign, played a key role in establishing guidelines to improve surgical safety (Gawande 2009). He was inspired by the checklists used by airline pilots to reduce error and hence the WHO Surgical Safety Checklist was developed (Haynes and others 2009). This checklist consists of 19 items specifically designed to reduce the …