We all make mistakes, at home and at work. Human errors are inevitable. But how often in veterinary practice do errors, particularly those that lead to drastic consequences for the animal or a client complaint, lead to recriminations and feelings of guilt all round?
In these enlightened times when we should be considering the health and wellbeing of our practice team, having an open culture where mistakes can be discussed is really important.
Errors in practice can be clinical or non-clinical. Oxtoby et al (2015) have analysed errors from Veterinary Defence Society claims, and they discuss the main causes of errors — human errors, system failures and lack of communication.
Looking at mistakes in practice can be a good way to get practice teams engaged with clinical governance and audit. This is also important as the Code of Practice requirement of the Royal College of Veterinary Surgeons (RCVS) is that Veterinary Surgeons and RVNs must ensure that clinical governance forms part of their professional activities (RCVS, 2012).
In human medicine, clinical audit has become an integral part of assessing standards of care. However, in veterinary medicine clinical audit is still not widely used. The systematic review from Rose et al (2016) explores this.
Background
So what is clinical governance? Well it certainly isn't rocket science. Scally and Donaldson (1998) defined it as: ‘A framework through which organisations are accountable for continually improving the quality of their services and safeguarding high standards of clinical care by creating an environment in which excellence in clinical care will flourish’.
Surely all practices aspire to this?
The seven main areas of clinical governance, which evolved during the introduction of clinical governance in the NHS (Nicholls et al, 2000), are usually defined as:
Clinical effectiveness is a measure of how well a particular procedure achieves the desired outcome, and practices by measuring their clinical effectiveness can promote good clinical care. The Royal College of Nursing (1996) defined clinical effectiveness as: ‘Doing the right thing, in the right way, for the right patient at the right time’.
So what is the ‘right thing’ in any particular case? Evidence-based veterinary medicine combines clinical expertise, the most relevant and available scientific knowledge, patient circumstances and owners' values to help us to find out what the right thing to do is. RCVS Knowledge (http://knowledge.rcvs.org.uk/evidence-based-veterinary-medicine/what-is-ebvm/) is a great source of further information on this, as is the Centre for Evidence-based Veterinary Medicine at the University of Nottingham (http://www.not-tingham.ac.uk/CEVM/).
Clinical effectiveness is assessed and improved by using clinical audit. Clinical audit at its simplest is the collecting and recording of clinical information with the aim of monitoring the quality of care. It can also be defined as a quality improvement process with the goal of continuously improving the quality of patient care.
When veterinary professionals talk about clinical audit they are usually thinking of outcome audits; these look at the results of a procedure or treatment, for example anaesthetic deaths or complications, or the results of particular surgeries. Practices that carry out an outcome audit of post-surgical neutering complications can benchmark their results at the vet audit websitehttp://www.vetaudit.co.uk/ (Vet Audit, ND). But these are not the only types of audit.
Process audits, which look at whether procedures are being followed, are also useful. For example a practice might audit compliance with a treatment protocol for diabetes mellitus in cats, or with the practice dispensing policy. Protocols should be drawn up following team discussion, and should be evidence based.
Significant event audit
The audit I would like to discuss in more detail in this article is significant event audit (SEA) or significant event review.
A significant event is an event thought by anyone in the team to be significant in the care of patients or the conduct of the practice (Pringle et al, 1995). It is a qualitative rather than quantitative form of audit, but still needs a structured framework to be effective.
Significant events can be serious, for example deaths under general anaesthesia. They can be moderate, as when laboratory results go astray and so delay treatment. They can be non-clinical, as with the wrong cremation in the example given below. Client complaints can often lead to significant event audits, while investigating ‘near misses’ can also be very useful.
Although significant events are often negative, situations where things went much better than expected can be reviewed as significant events too.
Benefits of a significant event audit
Holding a significant event audit or review is a great way to get the whole team together to learn from strengths and weaknesses in patient safety, animal care and client care. Getting something positive from a negative event can improve teamwork, communication and team morale, as indicated in the NHS Significant Event Audit guidance for primary care teams (Bowie and Pringle, 2008).
Process of a significant event audit
The first stage of a significant event audit is to identify the significant event, looking at the consequences either actual or potential of what happened.
In the case of serious harm, the meeting should be held as soon as possible. For less serious events it could be held as part of a regular, previously scheduled team meeting.
First, all the information about the event has to be gathered together; this could consist of clinical records, consent forms, anaesthetic records and letters of complaint from clients. Once this information has been collected the next step is to get an account of what happened from everyone involved while it is still fresh in their minds.
Then a meeting of the whole team needs to be organised. It is vitally important that this meeting is open, fair and honest. The purpose of this meeting is not to apportion blame, it is to encourage reflection and improvement. To this end, the person running the meeting must make clear to everyone that they are looking to improve practice systems and procedures, not to blame individuals.
The team should then try to analyse the incident as follows:
It may be that changes need to be made urgently or that systems need to be reviewed or indeed that nothing needs to change. It generally involves going away and looking at systems or protocols.
Before making changes to clinical protocols the evidence base should be investigated for that subject area.
Example significant event audit
Box 1 provides a scenario that could happen in any small animal practice.
Does this scenario ring any bells with you? Why is it that once one thing goes wrong it always multiplies?
In the ‘old days’ this may have resulted in looking to see whose fault this was, a telling off all round, a veterinary surgeon getting defensive but actually feeling guilty, and a negative atmosphere for the whole team.
In this case the practice manager shared the letter of complaint with the team. The initial reaction was for Anna to burst into tears and lose even more confidence; Pat to get defensive; and the registered veterinary nurses (RVNs) to look for which one of them was to blame for marking the crematorium bag with the wrong instructions.
Luckily Sarah, the Clinical Director, had been at a CPD event a few weeks before when someone from Practice Standards had been talking about clinical audit. They had mentioned significant event audit as a great way of taking an error or complaint, learning from it, and seeing if anything could have been done differently. If so, then changing protocols for the future to reduce the possibility of that error occurring again.
So the team decided to treat this as a significant event and held a meeting.
What happened?
The team thought that they already knew what had happened. But a few more details came out at the meeting:
Why did it happen?
Anna felt rushed as she realised that Mrs Jones had been waiting for a long time and was upset. This made Anna feel anxious and nervous and she had no RVN to help, which made things a lot worse. The receptionist tried her best but she was not as good as the RVNs at holding the vein up, so making Anna's task harder.
Mrs Jones told the receptionist on the phone and Anna in the consulting room that she wanted a private cremation for Choo, but at the end of the euthanasia Anna was so upset that she did not tell the RVN who had just walked in from the branch surgery. So the RVN put Choo into a communal cremation bag.
What was learned
After discussion by the whole team together, veterinary surgeons, RVNs and receptionists, they decided that making clients bringing pets for euthanasia wait in the waiting room during busy consulting periods was not acceptable and had been the initial cause of the problem. They agreed that an experienced RVN should always be available to assist all veterinary surgeons, but particularly less experienced colleagues. It was also decided that a more robust system was needed to ensure the correct cremation options were carried out.
What was changed
The following changes were made by the practice team.
The reception team
Have new practices to:
The nursing team
The veterinary surgeons and RVNs
Have changed standard practice so that:
The whole team
Response to the specific event
So what about Mrs Jones? Nothing can bring Choo's ashes back. The practice was open and honest with Mrs Jones about what had happened. They apologised profusely and asked Mrs Jones what they could do to help. Mrs Jones said that she just didn't want this to happen to someone else's cat.
The practice principal had a long chat with Mrs Jones and told her that they had made changes and implemented new protocols as a result of her complaint. Mrs Jones was very happy about that. The practice also put a photograph of Choo up in the waiting room, which was appreciated by Mrs Jones.
Practice systems and culture
I would urge practices to use those occasions when things go wrong to look at systems in the practice and see if changes are needed. Remember this is about changing systems, not about blaming people.
Practices with an open supportive culture that have started to reflect on mistakes and complaints and learn from them have found that this can turn a negative event into a positive learning experience and increase team morale.
Frank discussions analysing incidents, looking at all the factors involved, including human factors, system factors and patient (and owner) factors, can contribute to a bigger-picture approach. Acknowledging that non-medical factors can contribute to undesirable outcomes can shift the emphasis away from blame to what can be improved.
It is important for the mental health of the profession that we support colleagues and work in an open culture where mistakes can be acknowledged and discussed. The interesting article from Professor Albert Wu — Medical error: the second victim, discusses this in the human healthcare context (Wu, 2000).
I will finish with a quote from Liam Donaldson when he was Chief Medical Officer in 2004: ‘To err is human, to cover up is unforgivable and to fail to learn is inexcusable.’
Conclusions
Significant event auditing is widely used in human primary care practices; it is an effective way to get team members involved in analysing both clinical and non-clinical events. The results can be that training needs are identified, communication is improved, guidelines or protocols are drawn up after considering the evidence base, and/or further audits are planned.