References

Significant Event Audit – Guidance for primary care teams. 2008. http://www.nrls.npsa.nhs.uk/resources/?entryid45=61500 (accessed 7 November, 2016)

Nicholls S, Cullen R, O'Neill S, Halligan A. Clinical governance: its origins and its foundations. Br J Clin Govern.. 2000; 5:172-8

Oxtoby C, Ferguson E, White K, Mossop L. We need to talk about error: Causes & types of error in veterinary practice. Vet Rec.. 2015; 177 https://doi.org/10.1136/vr.103331

Significant event auditing. A study of the feasibility and potential of case-based auditing in primary medical care. 1995. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2560254/pdf/occpaper00124-0009.pdf

Rose N, Toews L, Pang DS. A systematic review of clinical audit in companion animal veterinary practice. BMC Vet Res.. 2016; 12 https://doi.org/10.1186/s12917-016-0661-4

Clinical effectiveness: a Royal College of Nursing guide.London: Royal College of Nursing; 1996

Royal College of Veterinary Surgeons. Clinical governance. 2012. http://www.rcvs.org.uk/advice-and-guidance/code-of-professional-conduct-for-veterinary-surgeons/supporting-guidance/clinical-governance/ (accessed 6 February, 2017)

Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England. BMJ. 1998; 317 https://doi.org/10.1136/bmj.317.7150.61

Vet Audit (ND) Post operative complications rate for routine neutering. http://www.vetaudit.co.uk/POC.htm (accessed 7 November 2016)

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Learning from mistakes: the use of significant event audit in veterinary practice

02 June 2018
10 mins read
Volume 9 · Issue 5

Abstract

All veterinary professionals should involve themselves in clinical governance. Clinical audit can be used to monitor the quality of care in a practice. Significant event audit is a qualitative form of clinical audit. It starts with a noblame meeting of the practice team; this looks at what happened, why it happened, what has been learned and what needs to change. The results can be that training needs are identified, protocols are changed or drawn up considering the evidence base, and further audits may be planned. Significant event audit is about improving systems, not about blaming individuals.

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:

  • Risk management
  • Practice and team management
  • Client and patient experience
  • Information
  • Training and continuing professional development (CPD)
  • Clinical audit
  • Clinical effectiveness.
  • 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:

  • What happened?
  • Why did it happen? Both the main reason and any underlying reasons
  • What has been learned?
  • What needs to change?
  • 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.

    The event

    It was a busy day, as usual, at the practice. Mrs Jones had rung and booked her old, much loved Siamese, Choo, in for putting to sleep. She was crying on the phone; Choo was 17 and a practice regular in the last few years. She spoke to a new receptionist who didn't know Mrs Jones; the receptionist, Pat, gave her an appointment later that afternoon.

    Mrs Jones arrived 10 minutes early as she was very anxious about the whole thing and wanted to give herself plenty of time. She took a seat in the waiting room, which was packed.

    As her appointment time came around the receptionist told Mrs Jones that the vet, Anna, was running 20 minutes behind schedule. Mrs Jones was sobbing into her hanky by this time.

    Eventually Mrs Jones was taken through into the consulting room. Anna, a fairly recent graduate, felt nervous because Mrs Jones was so upset. To make matters worse all the experienced RVNs were busy. Anna knew she couldn't let Mrs Jones wait any longer so she got the receptionist to help her.

    Mrs Jones asked Anna to make sure that Choo went for private cremation as she wanted to bury his ashes under his favourite tree in the garden.

    Anna's hands were trembling and she struggled to find a vein; Pat did her best but Choo was very wriggly.

    By this time Mrs Jones was beside herself. Once Choo had gone to sleep, she waited a few minutes but then realising how busy they all were she felt that she had to go.

    While Mrs Jones was on her way out, Pat reminded her to call back in a week to collect Choo's ashes.

    Just over a week later Mrs Jones psyched herself up to visit the surgery to collect the ashes, it brought it all back again and Mrs Jones was upset again.

    Pat then told Mrs Jones, in the waiting room, that unfortunately Choo had been sent for communal, not individual, cremation so there were no ashes. Mrs Jones ran out of the waiting room back to her car, in floods of tears.

    Unsurprisingly a few weeks later a letter of complaint arrived from Mrs Jones.

    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:

  • Anna was running late because three extra appointments had been slotted into her surgery
  • One of these was Mrs Jones — who was given a single appointment in the middle of a busy surgery
  • All the experienced RVNs were busy because one was assisting another veterinary surgeon with an emergency (a gastric dilatation-volvulus); one had been sent to the branch surgery to collect some medicines; and the RVN who was on the consulting shift was re-dressing a dog's leg on a RVN's appointment.
  • 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:

  • Always give euthanasia consultations at least a double appointment
  • Try to schedule them at less busy times
  • Ensure that they are highlighted on the computer appointment list
  • Take clients into a quiet consult room or allow them to wait in the car until their appointment.
  • The nursing team

  • Ensures a named consulting RVN is available for all consulting periods
  • Make sure a RVN is always available to assist with any euthanasia
  • If there is only one consulting RVN, then RVN appointments at the same time as a euthanasia are blocked out.
  • The veterinary surgeons and RVNs

    Have changed standard practice so that:

  • A tick box regarding destination of ashes has been added to euthanasia consent forms
  • All euthanasia consent forms with cremation directions are now attached to body bags
  • This is double-checked by a second team member on every occasion.
  • The whole team

  • Bereavement counselling training has been arranged for the whole team
  • The reception team is instituting an audit of client waiting times
  • Once this is complete there will be a review of consulting periods
  • Handling of euthanasia cases will be a discussion item at the next couple of practice meetings to review these changes.
  • 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 need to have an open, ‘no blame’ culture in order to adopt SEA successfully; the process should involve the whole team and be open and transparent. All significant events or near-misses should be reported and discussed
  • When clinical protocols need to be changed as a result of an SEA, the clinical team should be involved in looking at the evidence base and drawing up practice protocols, guidelines and checklists
  • There should be good communication and training to implement these protocols and guidelines, and they should be used by everyone
  • It may be that as a result of the SEA the team decides to follow up with outcome audits or process audits to monitor use of the new protocols.
  • 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.

    KEY POINTS

  • Significant events should be discussed by the whole team in a non-threatening open meeting.
  • They can be analysed to see what happened, why it happened, what has been learned and if anything needs to change.
  • Changes may involve drawing up or changing clinical guidelines after considering the evidence base, identifying learning needs or planning future audits.
  • Significant event audit is about improving systems in practice, not about blaming individuals.
  • Significant event audit can be part of an open culture where mistakes can be acknowledged and discussed and colleagues supported.