Mistakes, Errors and Foul-Ups: Practice-Based Evidence for Evidence Based Practice

  • Mark Turner The Royal Veterinary College, Hawkshead Lane, Hertfordshire, AL9 7TA, United Kingdom

Published:

2016-11-23

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DOI

https://doi.org/10.18849/ve.v1i4.69

Abstract

In human medicine, the management of care to ensure safety for the service-user constitutes an important element of the patient ‘journey.’ The name given to this discipline is patient safety. It is founded upon those elements of good medical practice which help avoid or mitigate human error.  Investigations in the U.S. first highlighted the alarming extent of medical error: Brennan et al. (1991) concluded that in the state of New York, the overall rate of adverse events was approximately 4% for hospitalised patients, which equated to over 13,000 deaths a year. Doctors looked to other safety critical industries and aviation in particular (Reason 1995), to address this phenomenon: there is now a wealth of research on the impact of various safety initiatives on measurable rates of harm. The World Health Organisation’s ‘Safe Surgery Saves Lives’ initiative - a campaign that advocates the use of a surgical checklist to standardise aspects of peri-operative care - is one example of aviation methodology successfully employed in a clinical setting (van Klei et al. 2012). The critical importance of effective communication, leadership and situational awareness has also been discussed at length in the human patient safety literature.

Objectives

Veterinary patient safety is an analogous discipline and researchers have attempted to understand more about the topic of veterinary medical error. However, the evidence-base for veterinary patient safety is sparse.  This presentation aims to summarise the evidence to date and highlight the benefits in practice of an emerging subject. 

Method

A search of the terms veterinary patient safety on the PubMed database from 1990 to 2016 was performed.

Findings

15 articles were identified as contributing to the veterinary patient safety literature.

Outcome

The available literature has addressed a number of areas. The use of checklists in a clinical setting has been proven to reduce the incidence of specific undesirable events: alterations to a standard anaesthetic protocol in light of a clinical audit led to a demonstrable improvement in one North American university hospital (Hofmeister et al. 2014).

Research into the progenitors of mistakes in practice reveal the effect of poor communication and a lack of team work (Kinnison et al. 2015). Research has also investigated vets’ attitudes toward error and their experiences of it. The psychological precursors to error in our industry seem to mirror those found in human medicine (Oxtoby et al. 2015). The evidence supporting a new attitude and approach to veterinary patient safety is growing.

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References

Brennan, T. A. et al. (1991) Incidence of Adverse Events and Negligence in Hospitalized Patients: Results of the Harvard Medical Practice Study I. The New England Journal of Medicine, 324 (6), pp. 370–376. http://dx.doi.org/10.1056/NEJM199102073240604

Reason, J. (1995) Understanding Adverse Events: Human Factors. Quality and Safety in Health Care, 4 (2), pp. 80–89. http://dx.doi.org/10.1136/qshc.4.2.80

van Klei, W. et al. (2012). Effects of the Introduction of the WHO "Surgical Safety Checklist" on In-Hospital Mortality: A Cohort Study. Annals of Surgery, 255 (1), pp. 44–49 http://dx.doi.org/10.1097/SLA.0b013e31823779ae

Hofmeister, E. H. (2014) Development, Implementation and Impact of Simple Patient Safety Interventions in a University Teaching Hospital. Veterinary Anaesthesia and Analgesia, 41 (3), pp. 243–8 http://dx.doi.org/10.1111/vaa.12124

Kinnison, T. (2015) Errors in Veterinary Practice: Preliminary Lessons for Building Better Veterinary Teams. Veterinary Record, 177 (19), pp. 492–492. http://dx.doi.org/10.1136/vr.103327

Oxtoby, C. et al. (2015) We Need to Talk about Error: Causes and Types of Error in Veterinary Practice. The Veterinary Record, 177 (17), p. 438 http://dx.doi.org/10.1136/vr.103331

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