Ditching the blame game: Effectively responding to medical errors
Medical errors can mean the difference between life and death, but at the same time, are very much a reality of veterinary practice. If humans are involved in a process, there will always be mistakes, said Lauren Forsythe, PharmD, a clinical assistant professor of pharmacy and the pharmacy service head at the University of Illinois Veterinary Teaching Hospital.
She presented the session "Error Prevention: How to Play Your Part" on March 17 at the 2023 Student AVMA (SAVMA) Symposium, which addressed processing systems within veterinary medicine for preventing harmful errors.
She referenced a March 2018 JAVMA study, which reported that, among 606 veterinarians responding to a survey, 73.8% had been involved in at least one near miss or adverse event.
"We need to change the question from 'Who is to blame?' to 'What is to blame?'" Dr. Forsythe said.
Mistakes involving surgery were the most common type of medical error, according to a 2015 Vet Record study about the types of errors in veterinary practice. One review of 74,485 veterinary cases found that almost 40% of adverse events could be linked to operations. Of these cases, the majority were from general surgery and orthopedics.
Another study, this one examining veterinary hospital processes, found that 54% of medical errors were drug related, followed by failures of communication. Primarily, the drug-related events occurred because of faulty administration processes, such as giving the wrong dose or treating the wrong patient.
Medication errors tend to occur when labelling is unclear, devices are designed poorly, medication is stored improperly, or error-prone abbreviations are used, Dr. Forsythe said.
Preventing medical errors
There is no mandatory reporting of medical errors in veterinary medicine for data analysis, but some institutions have created their own systems. For example, in 2015 Cornell University instituted a voluntary online incident reporting system in the small animal and large animal units of the College of Veterinary Medicine's Hospital for Animals.
Dr. Forsythe explained that the University of Illinois College of Veterinary Medicine created an incident reporting system modeled after Cornell's to unpack the occurrence of medical errors and near misses. She said the way medical professionals deal internally with these issues impacts the entire team.
"If we don't talk about medical errors, the same mistakes happen again and again," she said.
Dr. Forsythe led the session participants through the six steps of responding to medical errors, taken from a July 2018 article from the Veterinary Idealist blog. The steps are as follows:
- The patient should always come first.
As soon as an error is observed, ongoing damage should be immediately minimized.
- Notify the client right away.
Clients specifically want acknowledgement that an error happened. They want to know what the error was, why the error happened, and they want a genuine apology.
- Support the health care workers involved.
Often, the person who made the error is referred to as "the second victim" because they end up experiencing tangible suffering as a result of the mistake. It is important to ask them if they are OK and to help establish healing as they move forward.
It is critical to understand why a mistake happened. This is needed to share with the client and for making appropriate changes to systems in place. The point of the investigation is not to identify or assign blame. Instead, an important question to ask is, "Could another person in the same situation have made the same mistake?"
- Circle back to the client.
Clients need closure, including information about clinical implications, long-term prognosis, results of the investigation, and plans to prevent it in the future.
- Work to fix systems internally.
Creating a process to report, track, and investigate all medical errors, including near misses that didn't cause harm, provides valuable data for improvement.
"Adverse events should be used as opportunities to learn," Dr. Forsythe said.
Doing better next time
Dr. Forsythe said the old-fashioned idea of reeducation, or relying on people to remember more information, is not effective. Trying harder will not provide a solution, but changing systems of care will.
The focus should be on risk reduction, so there's less reliance on remembering, and tasks have redundancies to make it hard to do them incorrectly in the first place. This can look like mistake proofing, such as using bar codes for medication administration.
"We have in health care a lot of steps in place to make sure people have received a high amount of education before they get put in positions to make decisions," Dr. Forsythe said.
Leaders should make a commitment to providing high-quality, exceptional care and holding everyone—themselves included—accountable for quality improvement efforts.
"Punishment will only decrease reporting and be counterproductive to helping address these errors," Dr. Forsythe said. "Culture can have a bigger impact than equipment, technology, and facilities on outcome."
Medical error types and examples
Drug: Any issue with drug administration
Iatrogenic: Complication from procedure or treatment other than a drug
System: Delays, missed treatments, or protocol issues
Communication: Misidentified patient, confusion over orders, or failure to share information
Laboratories: Lost specimens, mislabeled samples, results not reported, delays, or improper studies
Oversight: Judgment issues, missed diagnosis, misinterpretation of data, or deviations from standard of care
Staff: Insufficient staff numbers, lack of access to needed staff, or incident during staff training
Equipment: Inaccessibility, wrong equipment, failures, or supply problems