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