The fourth in a series on developing safety in general practice from Catherine Auden at VetLed.
I know what it’s like.
There’s a lot of learning at vet school.
With the increasing availability of information via the web, online journals, blogs and social media, you could be digesting information from the moment you open your eyes until you fall into bed again that night.
So why read about Human Factors? You’re studying animals after all.
Perhaps you’ve thought a bit about people skills, communication and teamwork and suchlike and how this will impact you in veterinary practice? This is a good place to start but there’s more to it. All sorts of factors impact not only how we work but also how well we work.
As a new or soon-to-graduate vet, it is easy to focus heavily on your clinical skills. And yes, of course, none of us would disagree that these are super-important. But is there a disconnect between having great clinical skills, and actually delivering them?
Human factors bridge the gap between your clinical skills and your delivery of these skills.
Research shows that “basic cognitive limits have been identified as one of the leading causes of adverse events in medicine” [OXT15]. In fact, in 1991, studies at Harvard University [BRE91] published data showing that 98 000 patients per year were dying, not as a result of their condition but due to doctors’ mistakes. Further research published in 2000 by Kohn et al demonstrated that such error was not necessarily a result of professional negligence or even carelessness, but error made by capable medics. They were erring simply due to their own cognitive limitations and factors external to them in the environment in which they worked [KOH20]. As such it was publicly recognised that medical error was not simply a professional making a mistake that they could have “tried harder” not to have made, but a multi-factorial situation with myriad human factors involved.
This sort of data means we should all be pricking up our ears when it comes to the impact of HF on our own work. The field of veterinary human factors is growing but still in its infancy by comparison to the human medical world. We need to be aware of human factors as we work in veterinary practice and mitigate against the errors we could make, whether 20 days, or 20 years qualified.
"Experience is simply the name we give our mistakes" Oscar Wilde
How we are wired as human beings will impact how we react in certain scenarios. Throw in a few other human beings, wired as differently and uniquely as us and the situation becomes more complex. Add stress, time pressure, a busy day and a new surgical procedure and we see how simply completing a surgical procedure is only one factor in many that will affect our performance and thus the standard of care we can deliver to our patients!
Human factors are an integral part of you and those around you. Human factors will affect how you work. Disregard them at your peril!
Viewed wrongly, an awareness of these factors might add to the stress we feel as new graduates, but in actual fact, being aware of the factors that affect our performance means that we can take steps to manage them, thus reducing mistakes.
So what are Human Factors and how can we manage them as we step into the world of veterinary practice?
It’s a huge topic worthy of a degree course in itself but factors that even on day 1 in practice you will be familiar with such as fatigue, stress, cognitive limitations, team dynamics and much more will all impact on our ability to deliver best patient care, despite our great knowledge and skills.
In fact, cognitive limitations and poor non-technical skills, both key elements within Human Factors, have been shown to cause the majority of errors in veterinary practice.
“Sustained high performance has its basis in learning and improvement”.
A key factor in high performance is reporting. This includes positive events as well as concerns, near misses and incidents. However, reporting will be compromised if there is a fear of blame. This can be especially apparent for the new graduate, keen to impress, fearful of making mistakes and simply in the very early days of learning a trade.
We all understand that when you enter the veterinary profession as a new graduate it can be extremely hard to speak up. We don’t like admitting our mistakes, and as a new graduate we can be very fearful of making a mistake at all.
To err is human
Any vet who has been working for a length of time, will certainly have made a mistake or two on the way.
To err might be human, but it does take a certain sort of human to then openly admit their mistake, does it not? Or perhaps not a certain type of human, but a certain type of workplace culture in which we can admit the mistake? Hartnack et al report that mistakes will always occur but that a fear of castigation stops people speaking up [HAR13].
We talk thus of a culture of “psychological safety” (a term coined by Harvard Professor Amy Edmondson) [EDM16]. This is the creation of an environment in which all team members are safe, and feel safe, to take interpersonal risk to speak up without fear of judgement or animosity from colleagues.
It’s not easy to speak up is it though is it? No-one goes to work wanting to look incompetent, ignorant, intrusive or negative. So how to avoid this? Well, keep quiet. Keeping quiet works to protect you. But it doesn’t protect or develop the team. In face workplaces in which teams don’t speak up/offer ideas/ask questions are lower performing, less successful, and make less! Furthermore, not speaking up stalls learning, development and innovation in the team.
Take an example from human healthcare. Do better hospital teams make fewer medication errors? Research by Amy Edmondson [BUI14] showed initially that better teams made more mistakes, the opposite of what she had been expecting. It became clear on further research though that the better teams are not making more mistakes, but have a culture where they are more willing to admit and open to discuss their mistakes…and as such are a better performing team.
Safe as houses?
Is it worth developing our workplace psychological safety? Absolutely. Without doubt talking about our mistakes within a psychologically safe space leads to a better performing team.
But how to do this as a new graduate? It is certainly hard. But it is worth remembering that despite being new to the profession, you can still lead by example. You are a professional and you can demonstrate good practice to those around you without being in a leadership position.
Perhaps developing a way of talking about error in your practice is something you could raise at your practice meeting? Have you come across VetSafe? [VET1]. It is a confidential and anonymous reporting system from the VDS where errors/near misses can be inputted and where data is then collated both locally (your practice) and nationally. Perhaps this is something that your practice could start to use? Are you building relationships within the practice where perhaps others could talk about their near-misses and errors to you? Model the behaviours that you would like to see and be the start of something new and exciting in your practice.
“The most powerful leadership tool you have is your personal example” John Wooden
You may be a new or recent graduate, but you are the bosses of the future! You can start investing in a positive workplace culture now and building your safety mindset from the very first days of your veterinary career.
Has your interest been sparked? Drop us a line here, we’d love to hear from you – firstname.lastname@example.org
Cat Auden graduated from Royal (Dick) Veterinary College in 2010 and worked in both small animal and equine practice for a number of years. She takes her veterinary practice experience and passion for people into her current role having diversified into the growing field of veterinary human factors. As Head of Collaboration for Vetled, Cat works to develop the performance of veterinary teams across the country through an understanding of Human Factors. She has a growing interest in veterinary education and has always enjoyed supporting veterinary students both in practice and whilst working as a vet in a university town. She is delighted to also be part of the VetMINDS team working to support employers and employees suffering pregnancy loss. Out of work Cat likes spending time in the great outdoors with her young, energetic family and mischievous Border Terrier.
Brennan et al (1991) Incidence of Adverse Events and Negligence in Hospitalized Patients — Results of the Harvard Medical Practice Study I N Engl J Med 1991; 324:370-376
Institute of Medicine (US) Committee on Quality of Health Care in America; Kohn LT, Corrigan JM, Donaldson MS, editors. To Err is Human: Building a Safer Health System. Washington (DC): National Academies Press (US); 2000.
(Accessed 6/12/19 at: https://www.ncbi.nlm.nih.gov/books/NBK225182/ doi: 10.17226/9728)
Oxtoby, C. (2014), Patient safety: the elephant in the room. J Small Anim Pract, 55: 389-390
OXT15 Oxtoby et al (2015)
We need to talk about error: causes and types of error in veterinary practice
Veterinary Record 2015 177: 438
EDM16 Edmondson (2016) Why Psychological Safety Matters and What to Do About It https://rework.withgoogle.com/blog/how-to-foster-psychological-safety/
HAR13 Hartnack et al (2013), Critical incidence reporting systems – an option in equine anaesthesia? Results from a panel meeting. Vet Anaesth Analg, 40: e3-e8.
Edmondson A (2018) Creating Psychological Safety at Work in a Knowledge Economy – video https://www.youtube.com/watch?v=KUo1QwVcCv0
Edmondson A (2014) Building a psychologically safe workplace https://www.youtube.com/watch?v=LhoLuui9gX8
The Most Powerful Leadership Tool You Have: Your Own Example – John Hall, Influence & Co https://www.forbes.com/sites/johnhall/2017/03/05/the-most-powerful-leadership-tool-you-have-your-own-example/#763be7eedc52