Medical Errors in Veterinary Medicine

Medical errors occur daily and are a significant issue for patient safety. One university veterinary hospital reported 5.3 errors per 1,000 patient visits,¹ and 30% of errors reported through a voluntary reporting system involved medication errors.² In human medicine, a survey of 10,000 patients in the United Kingdom showed that 6.2% of participants experienced harm caused by treatment or care.² Understanding how these errors arise and are managed is central to improving patient safety.

What Is a Medical Error?

A medical error is an act of commission (ie, something performed incorrectly) or omission (ie, failure to do the correct thing) in planning or carrying out a task that may contribute to an unintended outcome.³

Errors are usually the result of interactions between human cognitive limitations (eg, slips, lapses, mistakes) and failures of systems. Slips and lapses are often caused by distraction; for example, working in a distracting or noisy environment can lead to the wrong medication being supplied or a team member being disturbed during tasks (eg, one team member affecting the attention of another by talking to them while monitoring anesthesia). Mistakes may also be caused by lack of knowledge or problems with applying knowledge (eg, not knowing a drug dose, miscalculating a dose by a factor of 10).

Errors are rarely caused by human failure alone and are more likely to occur with a lack of robust systems. System failures include poorly designed workplaces; lack of training; understaffing; rushed or stressed team members; and inadequate guidelines, protocols, checklists, or systems of work.

Blaming individuals or suggesting a team member try harder is unlikely to reduce errors; most medical mistakes are the result of flawed underlying systems, according to a report from human medicine.⁴ All potential contributing factors should be evaluated.

What is the Impact of a Medical Error?

Medical errors can have devastating effects on patients and can lead to economic losses when clients lose trust in the clinic. Health care professionals can also be affected. Making a mistake that causes harm to a patient can lead to feelings of fear and self-doubt, emotional distress, and physical symptoms.⁵ These incidents can even lead to team members considering leaving the profession.⁶

How an error is handled matters as much as the error itself. Treating these incidents as learning opportunities—focusing on what led to the event rather than assigning blame—can reduce distress for those involved. Practice leaders should be clear that reviewing what led to an error is about looking at the systems in place, not blaming individuals.⁷

What Happens After an Error Occurs?

Errors must be reported in order to ascertain whether changes in systems are necessary and to turn the situation into a learning opportunity. Having a reporting system for errors in place is important, but a culture of learning without blame should also be established so team members feel safe reporting errors and valuable information is not lost.

After an error has been reported, the error, or trends in errors, should be discussed by the team. Not all errors lead to harm; some errors are caught before they reach the patient and may be classified as near misses. For example, a Labrador retriever being moved from one part of the clinic to another slips the leash and runs towards an open side door, but a quick-thinking team member who happens to be nearby quickly shuts the door before the dog can reach it. This situation could easily have ended in disaster if no one was near the door, as the clinic is on a busy road, so discussing what might have happened and what measures could be put in place to prevent an incident like this is critical. Discussing serious events can be intimidating. Discussing near missescan be a great place to start; team members may feel safe to engage because there was no negative outcome.

Debrief Tools to Use After Errors Occur

Results should be discussed in a team debrief, with the aim of adjusting systems rather than blaming individuals, which should encourage team members to speak out when an issue is spotted and increase opportunities for learning. Debriefs can be used to help team members learn from positive and negative outcomes, near misses, and trends.

Debriefs should include a leader who collects all relevant information and ensures team members feel comfortable discussing the incident without fear of blame. The goal of improving systems to reduce the chance of recurrence of errors should be emphasized.

Hot Debriefs

Hot debriefs occur immediately after a serious event (eg, anesthetic death). Involved team members should stop for 5 minutes to check that all individuals are okay and briefly discuss the incident before discussing it at length later in a cold debrief.⁸

Cold Debriefs

Cold debriefs are more structured team discussions held days or weeks after the event where all information about the incident is collected together and discussed by the team.

Root-Cause Analysis

Debriefs should focus on root causes rather than quick conclusions. Root-cause analysis is a systematic approach to identifying the underlying causes of near misses and adverse events, looking beyond individual errors to uncover relevant system failures. The Royal College of Veterinary Surgeons Knowledge checklist (see Suggested Reading) provides a series of questions to help team members identify all contributing factors.

Acting on the result of the root-cause analysis meeting is vital and may lead to system changes, adjustments in guidelines, team training, and other improvements. Any changes should be reviewed (possibly by an audit) after a set time to determine whether the desired effect has been achieved.

Using the example of the incorrect medication being dispensed, blaming an individual or suggesting they take more care may or may not improve outcomes for that team member, whereas analyzing the root cause of the incident can lead to improvements for the whole team. Examples include improved lighting where medications are stored and filled, a tidier and better organized dispensary, updated dispensing protocols and team training, a double-check system with sufficient time, induction for new team members on dispensing, and audits of the dispensing process to reveal any gaps. These changes may improve patient safety.

Morbidity & Mortality Meetings

Morbidity and mortality meetings are regular debriefs held to discuss clinical cases with poorer-than-normal outcomes. During these meetings, team members are encouraged to identify harm, report problems, and share lessons to reduce recurrence. Often, these meetings revolve around several cases (eg, a series of cesarean sections that resulted in postoperative infections). These meetings benefit from structured discussions of the situation, background, assessment, any available evidence, and recommendations.⁹

Nonclinical Incidents

Not all medical errors are strictly clinical; the Significant Event Audit framework (see Significant Event Audit Walkthrough) involves a review of any event, including nonclinical incidents, that is significant to patient care or clinic conduct.¹⁰ Examples could include a patient being sent for group cremation rather than a requested individual cremation so individual ashes were not available for the client to collect or pathology samples being lost en route to the laboratory, delaying treatment and leading to repeat biopsies.

Conclusion

Debrief structures and tools are available (see Suggested Reading). Whichever tool is used, the priority should be to create a culture in which team members feel safe speaking up and learning from successes, negative outcomes, near misses, and trends. When errors are handled well, the benefits extend beyond patient safety to team member morale and practice culture.