Breaking the silence: medical errors and what we can learn
Medical errors are an unfortunate occurrence in veterinary hospitals everywhere, often despite the best veterinary care and intentions of the veterinary team. While human medicine regulating bodies have implemented guidelines for the disclosure of medical errors in order to learn from the mistakes and improve patient safety, no such guidelines currently exist in veterinary medicine. However, it is clear that documenting and disclosing medical errors has significant benefits for everyone involved. Patients receive necessary treatment subsequent to the medical error, concerns regarding otherwise unexplained problems are decreased, and the veterinary-client-patient relationship is strengthened. Ultimately, the veterinarians and technicians involved also have improved recovery from the emotional stress of making the error and clients will be less likely to engage in litigation. Most importantly, the safety of the hospital will be improved when medical errors are recognized and steps taken to avoid the same errors in the future.
Terminology
Almost every veterinarian or technician has witnessed or committed a medical error, which is described as an action or decision that retrospectively appears incorrect or results in a disappointing outcome. Every hospital encounters adverse events defined as unanticipated harm (i.e., injury, illness, death) caused by medical care. A preventable adverse event can be attributed to a medical error, such as a misinterpreted radiograph or incorrect drug calculation. A negligent adverse event occurs when the medical care provided failed to meet the standard of care, such as insufficient monitoring during anesthesia. In other words, an average or similarly trained veterinarian or technician would have been expected to recognize and prevent the error that caused the harm. Know that not all medical errors cause harm, not all adverse events causing harm result from medical errors, and not all adverse events resulting from errors are due to negligence.
Occurrence of medical errors
It is estimated that approximately 1.5 million preventable adverse events occur in the United States human medical field each year, with 44,000 to 98,000 human deaths being attributed to medical errors annually. It is likely that this number is actually even higher, given how often medical errors are unreported or undetected. Studies in Canada reveal that the overall incidence of human medical errors is approximately 7.5%. The highest medical error rates occur in the intensive care unit, operating room, and emergency room. Currently, the incidence of medical errors in veterinary hospitals is unknown.
Types of medical errors
Medical errors are often classified as diagnostic, treatment, preventive, or other. Diagnostic errors include an error or delay in making the diagnosis, failure to perform indicated tests, use of outdated tests, and failure to act on results of monitoring or testing. Treatment errors include errors in the performance of an operation, procedure, or test; errors in the administration of a treatment; errors in the dose or method of administering a drug; an avoidable delay in a treatment or responding to an abnormal test result; and inappropriate care or provision of care that is not indicated. Preventive errors include the failure to provide prophylactic treatment or inadequate follow-up after treatment, and other errors include miscommunication, equipment failures, or other system failures.
Etiology of medical errors
Unfortunately, some degree of error is inevitable with any human task. Nevertheless, there are various factors that can increase the incidence of medical errors. These include an increased workload, sleep deprivation, loud background noise, disorganized communication, too much or too little information, incomplete information during patient transfers, hierarchical barriers, different communications needs and expectations, failure to listen, equipment failure, negligence, insufficient training, and incompetence. Most veterinarians and technicians overestimate their ability to function while stressed. In fact, as stress increases due to anxiety or fatigue, thought processes and attention spans decrease and familiar exercises are performed poorly. Therefore, increased workload and sleep deprivation likely account for a large number of medical errors.
Medical errors in veterinary medicine
There is very little information available with regard to the incidence and type of medical errors occurring in veterinary hospitals. Results from a survey sent to recent veterinary graduates in the United Kingdom were published in 2004 and revealed that 78% of veterinarians responding to the survey answered “yes” to the question “Have you ever made a mistake (defined as an erroneous act or omission resulting in a less than optimal or potentially adverse outcome for a patient) since starting work as a vet?”. Of the respondents who provided additional details of their error, 74% attributed the error to lack of experience, 36% to lack of time, 26% to lack of supervision, 21% to communication problems with colleagues, 16% to communication problems with owners, 15% to lack of information, and 12% to inadequate equipment. Interestingly, 37% of respondents did not discuss the mistake with the owner, whereas 93% of respondents discussed the error with friends, family, or colleagues.
Appropriate handling of medical errors
Disclosure of medical errors requires courage and composure, effective communication skills, and the steadfast belief that an owner is obligated to know the truth. First and foremost, when a medical error is identified, ensure that the patient’s immediate needs are tended to by notifying a veterinarian about what happened. Second, recognize your own emotional needs and attempt to develop clarity regarding what happened. Third, prepare for the discussion with the owner, which will typically involve a team of people and a series of communications. Technicians involved in the medical error or who have a close relationship with the client might wish to be present for the discussion, in order to answer questions first-hand and provide emotional support for the client, respectively.
The tools used to disclose a medical error are similar to those used during the delivery of bad news. It is important to maintain an empathic and non-defensive demeanour while discussing the situation, problem, and all possible outcome scenarios. The explanation of what happened must be accurate and honest and a discussion of the steps taken to prevent a re-occurrence should occur. Do not delay the discussion if information is missing; instead, focus on what is known at the time and assure the owner that future discussions related to new information will take place. It is also important to make a genuine apology that expresses acceptance of responsibility for what occurred. Thereafter, invite questions, listen, and answer truthfully. Generally, an agreement to waive fees related to the hospitalization and/or adverse event demonstrates commitment to helping the patient recover and decreases the perception that only an attorney can ensure that the system behaves fairly.
Reducing medical errors
While the human ability to err cannot be changed, other circumstances in veterinary hospitals can be altered to help reduce medical errors. These include enhanced education related to medical errors, system changes, improved teamwork and communication, and increased reporting of medical errors. It is important to change the culture from one of “blame”, in which people are unwilling to accept responsibility for errors due to fear of criticism or punishment, to one of “just”. A “just” culture supports open dialogue and uninhibited reporting of medical errors as a commitment to quality patient care and to facilitate safer hospital practices. It involves a quick and thorough investigation of adverse events, extensive informal and formal communication, and hospital-wide learning including staff training and education.
This article is based on Dr. Holowaychuk’s presentation at the International Veterinary Emergency and Critical Care Symposium in San Diego, CA.CVT
