Significant events and the First Opinion Vet

The second in a series on developing safety in general practice from Catherine Auden at VetLed

Error reporting, or is there more to it? Significant event audit for the general practice vet.

Eleven A*s at GCSE, four As at A-Level, graduated with Distinction from a prestigious veterinary school. Sally SuperVet isn’t used to falling short of the mark. Sally is careful, thorough, a little anxious, but used to succeeding. Her first year in practice was tiring but exciting. Over the next few years she built up a group of clients who asked to have their consultations with her and her surgical skills were becoming really quite proficient.

Then Sally made a mistake.

No-one died, but it was significant and the client wasn’t happy. Neither was Sally’s boss.

To Sally it seemed like she was the only person ever to have made such a mistake. She’d never heard of anyone else in the practice making a mistake and her boss was very clear; this was Sally’s fault and she needed to sort herself out.

Seen-It-All-Sid isn’t worried about mistakes.

Of course they happen. But nothing ever really comes from them. The trouble was this time, the client wanted answers.

They were upset and wanted to know how this had happened, why this happened and how Sid was going to make sure it wasn’t going to happen again.

We’ve all made mistakes.

Some we’ve forgotten…some we will not forget quickly.

But as a cohort selected for perfectionism (for better, for worse!), we generally aren’t good at being wrong. We aren’t good at making mistakes. So it’s vital that we have a framework in each individual practice where it is safe to fail. Because if you haven’t already, you will before long.

We need to report our errors so others can learn too. This is a team game, it’s not singling someone out for public derision but all growing as one.

Of course it takes some humility to admit our mistakes. So this needs to be modelled in practice from the top down. Senior staff need to demonstrate their own willingness to admit error so that the workplace culture is one in which those lower down the chain are not afraid to do the same. To establish this we need to work in a place where there is accountability for our mistakes but this accountability is held within what is known as a just culture. This could involve some significant changes to your workplace. If you’re in charge, talk to your team. Do they think they could openly talk about their errors without judgement? How could things change in your practice to grow a culture where it is safe to fail?

But back to reporting our errors. Is this too simplistic an approach? Does reporting of errors really give us a true picture of what is going on? In fact it is equally important to report near-misses, where something could have gone horribly wrong, but didn’t. That “lucky” find of a swab hiding behind the mesentery just before closure, that time the nurse nearly clipped the wrong leg for a cruciate repair, the time those two black cats in the cat ward almost got each other’s meds. The lessons we can learn from near-misses is critical to building a picture of clinical practice and how it can be improved.

But what about when things don’t go wrong? Shouldn’t this be recognised too? Very much so. Apart from being great for team morale, it is important to audit when events go well so we can learn from this too, and not just our (probably rarer) mistakes!

We are perhaps as an industry lagging somewhat behind in this. Our human medic friends are already auditing significant events (though with varied effectiveness in different hospital trusts). Perhaps most pertinently after the tragic Bristol Heart Scandal[1] where one situation after another led to the loss of very many children’s lives. As assumed promoters of evidence-based (veterinary) medicine, surely we should be auditing our good and bad results and changing our practice accordingly?

At VetLed we fully believe in the benefits of improving workplace culture, building a “Just Culture” where it’s safe to fail and where the whole team grows as one. We love training and supporting practices to implement sustainable change and thus improve outcomes for both the animal receiving the care and the clinician delivering the care.

[1] https://www.gresham.ac.uk/lectures-and-events/the-bristol-scandal-and-its-consequences-politics-rationalisation-and-the-use

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 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.