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We need to talk about error

3 Nov, 15 | by Kristy Ebanks

By Catherine Oxtoby

A paper that has recently appeared in Veterinary Record exploring the causes and types of error in veterinary practice is the first phase of a three year PhD into mistakes in veterinary practice – a hugely neglected area of research in our profession. It wasn’t until I started researching the background to errors and mistakes in other industries that I realised how little attention our profession has shown to a topic which is the driving force of policy and procedures in other sectors.

What we found, was that vets are no different to anyone else. Our brains are wired the same way – we make mistakes for the same reasons, it’s just that when a vet makes a slip during surgery the consequences are serious. It’s all about context, rarely about competence and almost never about a lack of care. Psychological limitations, system failures in the form of poor communication, poor teamwork and badly designed equipment or packaging were major causes of error, not simply a vet having a bad day. It is vital that we understand that mistakes don’t happen because someone was being careless – it’s much more complicated than that, and blaming the clinician does nothing to prevent it happening again. What we need are simple tools to support clinicians, and training in non-technical skills to help reduce mistakes.

Patient safety influences many areas of practice – not just the obvious example of ‘why things go wrong’. Reporting and discussing error, the reactions of our piers and seniors in the aftermath of mistakes and the way we look at our systems to prevent recurrences, all reflect the culture and ethos of a practice, its visons, values and leadership. Actively engaging with the concepts of patient safety drives quality, empowers staff and increases efficiency as well as saving lives and law suits. The final two years of the PhD study will be spent investigating safety culture in veterinary practice – the force which drives attitudes and behaviours. I believe that this is where efforts to improve should be targeted, as it is the culture of the place which determines its willingness to embrace the changes which may be required for interventions such as surgery checklists and reporting systems to really work.

I hope the paper will shine some light on a difficult and sensitive subject in the profession. The vast majority of veterinary surgeons and nurses are dedicated, compassionate people who care deeply about both their patients and their clients, but they are also human beings. We need to recognise the things which impair their performance and build resilience into our personnel and systems to ensure consistent quality of care, through a better understanding of the true causes of veterinary medical error.

More details can be found here

 

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