[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-0-en-105":3,"doc-seo-408915-105":59,"doc-detail-408915-en":131},{"code":4,"msg":5,"data":6},0,"success",[7,13,18,23,28,33,38,43,48,51,55],{"id":8,"doc_module":4,"doc_module_name":9,"category_name":10,"show_sort_weight":11,"slug":12},1,"Document","Story & Novel",90,"story-novel",{"id":14,"doc_module":4,"doc_module_name":9,"category_name":15,"show_sort_weight":16,"slug":17},2,"Literature",80,"literature",{"id":19,"doc_module":4,"doc_module_name":9,"category_name":20,"show_sort_weight":21,"slug":22},4,"Exam",70,"exam",{"id":24,"doc_module":4,"doc_module_name":9,"category_name":25,"show_sort_weight":26,"slug":27},5,"Comic",60,"comic",{"id":29,"doc_module":4,"doc_module_name":9,"category_name":30,"show_sort_weight":31,"slug":32},6,"Technology",50,"technology",{"id":34,"doc_module":4,"doc_module_name":9,"category_name":35,"show_sort_weight":36,"slug":37},7,"Healthcare",40,"healthcare",{"id":39,"doc_module":4,"doc_module_name":9,"category_name":40,"show_sort_weight":41,"slug":42},8,"Research & Report",30,"research-report",{"id":44,"doc_module":4,"doc_module_name":9,"category_name":45,"show_sort_weight":46,"slug":47},9,"Religion & Spirituality",20,"religion-spirituality",{"id":46,"doc_module":4,"doc_module_name":9,"category_name":49,"show_sort_weight":46,"slug":50},"World Cup","world-cup",{"id":52,"doc_module":4,"doc_module_name":9,"category_name":53,"show_sort_weight":52,"slug":54},10,"Lifestyle","lifestyle",{"id":56,"doc_module":4,"doc_module_name":9,"category_name":57,"show_sort_weight":24,"slug":58},19,"General","general",{"code":4,"msg":60,"data":61},"ok",{"site_id":62,"language":63,"slug":64,"title":65,"keywords":66,"description":67,"schema_data":68,"social_meta":124,"head_meta":126,"extra_data":128,"updated_unix":130},105,"en","coress-feedback-cases-from-the-confidential-reporting-system-for-surgery","CORESS Feedback - Cases from the Confidential Reporting System for Surgery","","CORESS Feedback documents surgical safety lessons drawn from the Confidential Reporting System for Surgery (CORESS), an independent charity. It explains how past cases can be searched through an online case database and how published cases may be acknowledged for continuing professional development and competence progression. The report presents vignettes on equipment familiarity and correct-site practice, including near-miss laparoscopic port injury risks and a wrong-side varicose vein treatment incident, emphasizing thorough equipment checks and effective team brief safety standards.",{"@graph":69,"@context":123},[70,84,106],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/coress-feedback-cases-from-the-confidential-reporting-system-for-surgery/408915/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/coress-feedback-cases-from-the-confidential-reporting-system-for-surgery/408915.png","ImageObject",300,407,{"name":92,"@type":93},"Himbo","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-29","2026-09-28",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",12,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"What is CORESS and what is its purpose in surgical practice?","Question",{"text":113,"@type":114},"CORESS is a confidential reporting system for surgery. Its purpose is to promote safety in surgical practice within the NHS and the independent sector.","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"What safety lesson is highlighted in Case 323 about laparoscopic ports?",{"text":118,"@type":114},"The case emphasizes checking equipment thoroughly, since an unintended port with a cutting blade was used even though equipment had been discussed in team briefings.",{"name":120,"@type":111,"acceptedAnswer":121},"What went wrong in Case 324 involving varicose vein treatment?",{"text":122,"@type":114},"The wrong leg was treated: both legs had similar varicosities and were marked, but the operating surgeon had not reviewed the full records and did not confirm the correct side with the patient.","https://schema.org",{"og:url":83,"og:type":125,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":127,"canonical":83},"index,follow",{"doc_id":129,"site_id":62},408915,1791036060,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":92,"user_avatar":134,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":105,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":81,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":144,"read_time":39,"preview_page_count":4},687197100911,"https://ap-avatar.wpscdn.com/avatar/a000239b6f1da00475?x-image-process=image/resize,m_fixed,w_180,h_180&k=1785132997149421697","CORESS FEEDBACK  \nDOI: 10. 1308/rcsann.2025.0117  \nCORESS Feedback: Cases from the Confidential Reporting System for Surgery  \nCORESS is an independent charity. Past CORESS cases can now be identified using a searchable CORESS case database, available via our website ([coress.org.uk](coress.org.uk)). We are grateful to those who have provided the material for these vignettes, some of which come from NHS England and Getting It Right First Time reports. The online reporting form is available on the CORESS website, which also includes previous Feedback reports. Published cases are acknowledged by a Certificate of Contribution, which may be included in the contributor’s record of continuing professional development, or which may form part of appraisal or annual review of competence progression portfolio documentation. Contributions from surgeons in training are particularly welcome.  \nHJ Corbett  \nCORESS Programme Director  \nW Hawkins  \nCORESS Deputy Programme Director on behalf of the CORESS Advisory Board  \nCORESS is a confidential reporting system for surgery. The purpose of CORESS is to promote safety in surgical practice, both within the NHS and in the independent sector.  \nUnfamiliar equipment leading to laparoscopic port injury  \nCase 323  \nA 28-year-old woman who had had no prior abdominal surgery presented with recurrent lower abdominal pain and requested diagnostic laparoscopy when investigation options were discussed. On the day of surgery, the surgeon requested a particular 12 mm disposable port but the operating theatre staff were unable to find the requested port. Three alternative ports were shown to the surgeon, who selected the port they wanted to use.  \nAn open technique was employed to insert the primary port atthe umbilicus but the fascial opening was not quite wide enough and insertion required a ‘push’, which was followed by a ‘give’. Two further ports were inserted under vision. During inspection of the small bowel, small bowel content was seen and a bowel injury then identified. The umbilical port site was enlarged and the bowel injury repaired. Subsequent inspection of the original port and trocar revealed that it was not the port that the surgeon had intended to use, and that the port used had a cutting blade within it, which became exposed when pressure was applied to the port.  \nReporter’s comments  \nThankfully, although the patient needed a prolonged stay in hospital, she made an uneventful recovery. During debrief, the surgeon noted that they were not familiar with the port they had used and did not realise that there was a cutting blade within it. The theatre staff were sure that they had opened the port that was requested. The lesson here is in checking the equipment thoroughly, and even though the ports were discussed during  \nthe initial team brief/huddle and mentioned at ‘time out’, the correct port was not opened.  \nCORESS comments  \nThis was a ‘near miss’ in that a more catastrophic injury to the vasculature could have occurred. Modern-day surgery has seen a huge increase in disposable equipment, with many of these pieces of equipment having their own particular design features. Individual surgeon preferences, combined with supply chain issues, increase the likelihood of the surgical team encountering unfamiliar equipment. The ‘team brief’ step of the revised National Safety Standards for Invasive Procedures (NatSSIPs2) sequential standards is the appropriate time to discuss (and if possible inspect) the available equipment.1 Consideration should be given to postponing the case if suitable equipment isnot available or if lack of training will put patient safety at risk.  \nReference  \n1. Centre for Perioperative Care. The National Safety Standards for Invasive Procedures (NatSSIPs) . [https://cpoc.org.uk/guidelines-resources-guidelines/national-safety](https://cpoc.org.uk/guidelines-resources-guidelines/national-safety)[-standards-invasive-procedures-natssips](-standards-invasive-procedures-natssi","cbCaietgcDLlLfze","https://ap.wps.com/l/cbCaietgcDLlLfze","pdf",189461,"English","# CORESS Feedback\n## Case 323: Unfamiliar equipment leading to laparoscopic port injury\n## Case 324: Wrong-side varicose vein treatment","[{\"question\":\"What is CORESS and what is its purpose in surgical practice?\",\"answer\":\"CORESS is a confidential reporting system for surgery. Its purpose is to promote safety in surgical practice within the NHS and the independent sector.\"},{\"question\":\"What safety lesson is highlighted in Case 323 about laparoscopic ports?\",\"answer\":\"The case emphasizes checking equipment thoroughly, since an unintended port with a cutting blade was used even though equipment had been discussed in team briefings.\"},{\"question\":\"What went wrong in Case 324 involving varicose vein treatment?\",\"answer\":\"The wrong leg was treated: both legs had similar varicosities and were marked, but the operating surgeon had not reviewed the full records and did not confirm the correct side with the patient.\"}]","CORESS Feedback - Cases from the Confidential Reporting System for Surgery | PDF",1790580924]