The newsletter written by clinicians for clinicians about lessons learned from deaths investigated by the Coroners Court.
The first edition of the Clinical Communiqué for 2019 discusses fixation error, the phenomenon whereby a person or group falls into a pattern of thinking that there is only one possible explanation. This can take several forms, including task fixation on a procedure, or diagnostic fixation to the exclusion of other possibilities, as unfortunately demonstrated in the two cases presented.
Future Leaders Communiqué
Welcome to the April edition of the Future Leaders Communiqué. As return readers will know, each edition of the Future Leaders Communiqué presents cases of preventable health care-related deaths and explores the systemic issues and errors identified in the ensuing coronial investigations. All junior medical officers (JMOs) working in a hospital setting will relate to these issues – I’m sure we can all recount a ‘near-miss’ situation that has stuck with us and informed our day-to-day work.