VETgirl December 2024 BEAT e-Magazine

QUARTERLY BEAT / DECEMBER 2024

or inter-departmentally. Ineffective communication failures can lead to an increased risk of sentinel events. Increased errors in communication often occur during the transfer of care or change of shift, “the handoff.” It has been suggested that using a system or tool to alleviate missed or vital information, such as those adopted in human medicine, can, and have been, applied to the veterinary setting. An example of this would be the widely adopted I-PASS patient handoff system, which stands for the following:

TEAM WILLINGNESS FROM ALL TEAM MEMBERS FOR PATIENT- CENTERED CARE AND SUPPORTIVE TEAM ENVIRONMENT It is important to recognize the strengths and weaknesses of a team, and to create a culture of respect that not only allows, but promotes learning and development. Having approachable team members opens the door for communication and allows for questions to be asked if confidence is low or a lack of knowledge exists. Creating a culture of team and improved patient care. Medical errors occur frequently in veterinary hospitals. Whether incidents did or did not result in patient harm, the potential to cause significant morbidity or mortality exists. Whether or not an error results in harm, it is important to encourage a willingness and commitment from all team members to follow and modify systems when needed to promote interventions for error reduction.

ESTABLISHING A PATIENT SAFETY CULTURE IN VETERINARY MEDICINE

I = illness severity P = patient summary A = action list S = situation awareness and contingency planning S = synthesis by receiver

TIFFANY GENDRON CVT, VTS (ECC), VETgirl CE Specialist

This system was developed based on best handoff practices cited in the literature, resident feedback from a pilot study, and observations made by faculty of the handoff process.6 This is an essential tool that can be utilized to promote patient safety.

Everybody makes mistakes; nobody is perfect! In this VETgirl article, Tiffany Gendron, CVT, VTS (ECC) VETgirl CE Specialist will review medical errors in veterinary medicine and what you can do to turn these mistakes into opportunities for improvement.

REFERENCES

STANDARD OPERATING PROCEDURES (SOP)

It is true what they say, “To err is human.” Medical errors and near misses are a concern in both human and veterinary healthcare. As members of a compassionate profession, the incidence of medical errors can pose a significant risk to the mental health of veterinary professionals. However, some measures can be taken to reduce the number AND frequency of medical errors. This is a multi-tiered approach, but first and foremost, it comes from recognition of where the errors occur, followed by a resolution strategy. No quick fix here, folks; you’re going to have to put in the work! Patient safety is at the forefront of care and the number one reason we should advocate to reduce medical errors and promote a patient safety culture (PSC). The number of events that relate to patient safety are vast and can vary from an error that did not cause harm to one that resulted in a negative consequence, including severe injury or death. A 2020 multicenter observational cohort study looked at the incidence of errors, degree of error, the severity of illness, and patient- to-technician ratios and what effect that had on the incidence of major medical errors in an ICU setting. It was noted that a substantial reduction in major errors could be achieved by maintaining patient-to-technician ratios at ≤4. 1 A technician’s experience and the severity of patient illness are also associated with error incidence and should be taken into consideration when scheduling staff. So, what can we take from this? We need adequate staff for the severity of illness and case load. I’m not living in a dream world; I understand staff shortages are REAL. However, a consideration may be case diversion. Set criteria for caseload and staffing ratios and stick to it to keep your staff happy and patients safe!

Errors can result from system failures such as communication, design of product or equipment, leadership and organization (workflow, staffing, management), or active failures, which include lack of technical ability, individual factors, and cognitive limitations (mistakes, distractions, stress). It is essential to recognize that errors are multifactorial and do not lie strictly in the hands of those with whom the error occurred. Rather, we should look at the systems in place to shift from an individual- focused framework (“blame game”) to a system-based approach for error management and mitigation. James Reason developed the Swiss cheese model, which has been used in many industries to analyze safety efforts to identify problem areas or “holes” in the system that could lead to error. The aim is to identify and incorporate mitigation strategies to prevent/ reduce errors.

1. Hayes G, Bersenas A, Mathews K, et al. A multicenter observational study investigating care errors, staffing levels, and workload in small animal intensive care units. J Vet Emerg Crit Care 2020;30(5):517-524. 2. Wiegmann DA, Wood LJ, Cohen TN, et al. Understanding the "Swiss Cheese Model" and Its Application to Patient Safety. J Patient Saf 2022;18(2):119-123. 3. Gibson J, Brennan ML, Oxtoby C, et al. Ethical challenges

SOPs provide an outline of how tasks are to be completed. SOPs help to eliminate oversight of important and, in some instances, critical aspects of patient care. The use of checklists provides a benefit to the team as it improves consistency in a step-by- step process that helps prevent medical oversights and errors. A surgical checklist that provides a list of tasks to be performed from the preoperative to the postoperative phase would be a great example of this. The number of steps that occur from surgical admission to recovery and discharge are numerous, and a missed step can prove deleterious to the patient. TRANSPARENCY IN ERROR AND REPORTING There is no mandatory reporting of medical errors in veterinary medicine; however, we have an ethical responsibility as veterinary professionals to do so. In some facilities, a medical reporting system has been created. In my opinion, it is important to instill a culture of patient first! Is it hard to admit when you are wrong or made a mistake? SURE is! The understanding is that leadership will encourage omissions of error, thereby improving processes without demeaning the individual involved. Simply stated, we cannot fix what we don’t know is broken. Reporting an error may lead to mental anguish for those employees involved, and for this reason, a SOP should be in place to provide the necessary resources to cope with the event.

experienced by veterinary practitioners in relation to adverse events: Insights from a qualitative study. Vet Rec 2023;193(12):e3601.

4. Oxtoby C, Ferguson E, White K, et al. We need to talk about error: causes and types of error in veterinary practice. Vet Rec 2015;177(17):438. 5. Wallis J, Fletcher D, Bentley A, et al. Medical Errors Cause Harm in Veterinary Hospitals. Front Vet Sci 2019;6:12. 6. Cummings O, Krucik D, Carroll J, et al. Improving within-team communication to reduce the risk of medical errors. J Am Vet Med Assoc 2022;260(6)600-602. 7. Starmer AJ, Spector ND, Srivastava R, et al. I-PASS Study Group. I-pass, a mnemonic to standardize verbal handoffs. Pediatrics 2012;129(2):201-204.

Create a patient safety culture (PSC) by implementing the following strategies:

• Communication strategies • Standardized evidence-based procedures • Transparency in errors and reporting protocols • Team willingness from ALL team members for patient-centered care and a supportive team environment

IMPROVING COMMUNICATION Team communication is a vital aspect of efficiency and delivery of quality care to our patients. Communication failures can occur with either the client (e.g., missed opportunities for informed consent or not hearing the client)

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