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Qual Saf Health Care 12:320 doi:10.1136/qhc.12.4.320
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Action Points

Q: Can releasing performance data reduce litigation?

In this case report from Australia the authors describe how data from a trainee anaesthetist’s performance monitoring programme turned anger into praise. The anaesthetist inadvertently inserted a pulmonary artery catheter sheath into a patient’s right carotid artery, resulting in haematoma, distress and dyspnoea. The patient’s family complained that a trainee had been allowed to risk a patient’s life, and asked how to start formal proceedings. The trainee, who was taking part in a monitoring programme, agreed for his professional record to be shown to the relatives. It showed that he had a very low complication rate for the procedure. “The family then understood more clearly that the sequence of events represented an unfortunate misadventure that could have happened in the hands of any experienced anaesthetist”, write the authors. “They …

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