Learning more about procedures that can improve patient safety can enhance our ability to treat animals effectively.
Patient safety is defined as: ‘The absence of preventable harm to a patient and reduction of risk of unnecessary harm associated with healthcare to an acceptable minimum’ (World Health Organization (WHO), 2023). While staff are committed to helping patients at all times, they are nevertheless human and capable of making unintentional mistakes. Patient safety is therefore focused on identifying safety incidents and learning, so that that the same error is not made again by a different staff member.
An important part of patient safety is the idea that blame is a pointless exercise: punishing a staff member for an action that they already feel bad about will only make the veterinary practice a more dangerous place for patients, because it deters others from admitting their errors. In a healthy practice, there needs to be safe accountability for when mistakes are made, they need be seen as ‘good people make mistakes’. Team members are encouraged to take personal responsibility, but always receive support to move forward from sometimes traumatic events. This helps them grow personally and professionally.
Human error is normal and any mistake can have serious consequences when working within the veterinary industry. Patient safety in veterinary care is a discipline that uses up-to-date research about human error and accident prevention to minimise the frequency of adverse events (Oxtoby, 2014).
Patient safety is made up of behaviours, but also the routine use of ‘tools’ or frameworks. If we take a systematic approach to using an established framework to introduce patient safety in veterinary practices, we can base a structure on the National Patient Safety (The Joint Commission, 2023) guide as a good starting point for a framework which is successfully used in the NHS.
Safety huddles
The NHS advocates the use of ‘safety huddles’ to support effective communication at key points in the care of individuals, to improve safety. A safety huddle is a short multidisciplinary briefing, held at a predictable time and place, and focused on the patients most at risk (Lamming et al, 2021). Effective safety huddles involve agreed actions, are informed by visual feedback of data and provide the opportunity to celebrate success in reducing harm (Rowley, 2019). Safety huddles:
- Enhance teamwork through communication and co-operative problem-solving
- Share understanding of the focus and priorities for the day
- Improve situational awareness of safety concerns.
The topics to assess can be chosen to fit within your veterinary practice and be very useful in ensuring risks are highlighted and plans executed to reduce these specific risks.
Clinical governance
A common definition of culture is ‘the way tasks are completed’ in the veterinary practice. In veterinary practices, work culture describes a group of attitudes, beliefs and behaviours that team members share and exhibit. This might be a rule that everyone adheres to regarding the completion of tasks, but ideally it should be a method of following standard of practice procedures. The opposite of a healthy practice culture would be one in which team members feel inhibited from speaking up about what they see, or reporting accidents of care, and perhaps a workplace in which rudeness is accepted (Mosedale and Turner, 2022). As well as making going to work an unpleasant experience, research also suggests that incivility has a direct impact on care quality (Riskin et al, 2015; Katz et al, 2019; Mosedale and Turner, 2022).
It may well be considered common that a blame culture exists within practices, and that communication is based on notions of rank and hierarchy in some practices. An effective way of reversing these trends is to explicitly place the goal of quality improvement at the heart of veterinary work. In many ways, quality improvement helps prevent a bad culture taking root, and supports togetherness and learning to create better standards.
Quality improvement can be considered a framework used to systematically improve patient care. This can be shown using the whole team in the veterinary practice. The team works together to make changes that will lead to better patient outcomes, better system performance and better professional development (Mosedale and Turner, 2022). Quality improvement is a systematic approach to practice performance, investigating how things are done now and how they might be improved in the future. It uses auditing tools to identify areas for improvement, and to test changes, and team-based behaviours that improve the flow of communication around the clinic and learning (Mosedale and Turner, 2022).
Quality healthcare should be safe, timely, effective, efficient, animal welfare-focused, client-values focused, and veterinary-team focused, and quality improvement is the means to accomplish these goals (Pantaleon, 2019).
Clinical audits, significant event discussions and tools such as guidelines, checklists and systems of work, can help veterinary practices to make a start with quality improvement. RCVS Knowledge (2020) has many resources for busy veterinary teams to use, including continuing professional development (RCVS, 2023).
Clinical audit
Clinical audit is an effective way of progressively improving standards and quality in practice (Viner, 2009). There is a large amount of unused data in veterinary practices that can provide a wealth of information for best practice recommendations. Staff members have the ability to look at evidence and involve team members in drawing up guidelines for standard of practice protocols. Team members can use these data, along with clinical expertise and the needs of the particular patients and clients, to make well-informed decisions about recommendations or changes that need to be made. This approach to clinical situations can contribute to a healthy practice culture.
Clinical audit is a quality improvement process which aims to improve outcomes for patients by looking at processes in the practice. It requires an environment in which problems can be freely discussed. A blame-free culture is essential to allow open and honest discussion with a focus on improvement, and to allow staff members to feel safe and accountable in their workplace (Mosedale and Turner, 2022).
If clinical audit is used properly it can be a valuable addition to quality improvement, revealing issues before they cause an error. Clincial audit can also help to improve practice culture by having an open environment where everyone is listened to and change is embraced.
Significant events
The general practitioner appraisals guide defines a significant event as: ‘any unintended or unexpected event, which could or did lead to harm of one or more patients. This includes incidents which did not cause harm but could have done, or where the event should have been prevented’ (GP Appraisal Guide, 2022; RCVS Knowledge, 2024).
It is not only negative outcomes that can be audited. Good, positive outcomes can also be audited, as another method of learning. Central to this process is the analysis of the whole ‘system’, as accidents can be seen as the result of interactions between elements of the ‘system’ and staff.
It is also beneficial to consider the problem as a problem of a process not a problem of staff members, highlighting issues with the process and providing an adequate safety net for staff members.
Changes made after significant event analysis are often innovative improvements made by employees on the ground. Accidents are seen as lessons for the clinic, rather than as a finger pointing and blame exercise. This should not be seen as a process to fear (Mosedale and Turner, 2022).
Checklists
Checklists can be very successful in allowing staff members to provide consistency of care and ensure no important steps in the care delivery are missed. Some examples include for surgical procedures or ward handovers. They can provide protection not only for patients but also team members by having a planned and structured protocol in place. Checklists provide more added benefits in communication and decision making, and help with steps that may easily be missed. They encourage a culture of teamwork, improving confidence and assertiveness in raising issues, and can reduce hierarchies between staff members.
Using medicines safely
The responsible use of veterinary medicines for therapeutic and prophylactic purposes is one of the major skills of a veterinary surgeon and crucial to animal welfare and the maintenance of public health (RCVS, 2023). Veterinary medicine is currently lacking studies on medication safety, although the importance of evidence in protecting animals from medication errors is highly discussed. Veterinary professionals have an important role in ensuring medication safety, and must ensure there are procedures in place to reduce errors. Some of these procedures may include standard of practice procedures for pharmacy areas and dispensing of medications. Good staff training can assist with preventing dispensary errors and errors can be corrected via thorough countersigning procedures.
Prevention of infection
Prevention of infection is a key component of patient safety. Disease transmission is one aspect of an infection control strategy or protocol. Three elements are required for successful disease transmission (O'Dwyer, 2013):
- A source of infection
- Host susceptibility
- Routes of transmission (direct, aerosol, vector-borne).
These routes of disease transmission need to be taken into consideration whenever hospitalising patients, and determining their bios-ecurity status (O'Dwyer, 2013).
Hand hygiene
Hand hygiene is one of the most important aspects of infection control, but is one of the most difficult to enforce in hospitals. There are a number of reasons that have been cited as contributing factors to this including (Nakamura et al, 2012):
- Guidelines are too complex and hard to follow
- Staff are too busy z Lack of education about importance
- It is hard to change old habits
- Good hand hygiene practices cause drying and dermatitis of the hands.
Hand hygiene implementation plans must take all of these factors into consideration when guidelines are developed and used (O'Dwyer, 2013).
Cleaning
With the emergence of methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-resistant S. pseudintermedius (MRSP) in veterinary hospitals, cleaning and use of correct dilution rates of disinfectants have taken on greater importance at reducing hospitalacquired infections (O'Dwyer, 2013). Recovery of bacteria from the environment has been documented months and years after the environment becoming infected (Gerba, 2015). It is important to have strict cleaning protocols in place that all staff follow, with correct use of personal protective equipment such as gloves and aprons. The NHS advocates the use of gloves and aprons in conjunction and not solely. If a task warrants gloves then an apron should be used and vice versa.
Isolation facilities/barrier nursing
An important aspect of infection control is the isolation of patients that serve as a risk to either humans or other patients. In most cases, isolation facilities in veterinary hospitals have been poorly designed and have often been added as an afterthought. Isolation facilities must allow isolation of individuals from one another and must also have an area where members of staff entering the isolation space can put on and remove appropriate and effective personal protective equipment or devices to protect themselves and prevent the spread of infection (O'Dwyer, 2013). Personal protective equipment can be seen by healthcare workers as an impediment or a hassle, and education and monitoring of adherence are extremely important parts of an effective policy. Staff should also be educated or have guidelines to consult regarding what personal protective equipment is necessary depending on the known or suspected pathogens in question.
Conclusions
Designing an effective framework for patient safety is multifactorial and should be designed with specific topics in mind. Practice culture must be adapted to allow safe mistakes to be made. Staff training is also important. Practices must ensure new staff are aware of the protocols, and how they should be carried out, and also ensure existing staff are up to date on accepting the idea of change (O'Dywer, 2013). Fear of mistakes is a negative thought process and any changes made should ultimately change this fear into positive accountability, which is a huge learning process.
KEY POINTS
- Clinical governance supports a framework to help improve care provided.
- Positive practice culture can be empowering for staff.
- Checklists can be very successful in allowing staff members to provide consistency of care and avoid errors.