Mistakes happen. It’s a fact of life. Whether at work, at home or out and about, as humans we simply aren’t perfect all of the time! But when errors at work can seriously affect the outcome of a case, or even risk the death of a patient, it suddenly becomes a lot more serious.
Are mistakes just a fact of practice life and so we should keep the VDS on speed-dial? Or, as scientists, can we learn about the source of errors and then implement practical ways to mitigate against them?
As vets, we are highly skilled people with good intentions; no-one enters this profession to wilfully cause harm. Mistakes often happen through a series of unfortunate and unlikely events.
hazards and prevent adverse events (Reason, 1990)
As qualified professionals we naturally put up barriers to improve safety. When a patient undergoes a general anaesthesia, we ensure the patient has not eaten that morning, we assess the heart and lungs, we administer an appropriate pre-med, we use multiparameter monitoring, etc. Each of these actions is represented by the yellow “barriers” in Figure 1, blocking the potential hazard (the inherent risks of a GA) and preventing an adverse event (crash under GA).
more like the “Swiss cheese model”
Each barrier is not completely fail-safe and the reality is rather more like the Swiss cheese model (Figure 2). There will be holes where things could go wrong despite the safety barriers, and when these holes all line up, the hazard becomes an actual adverse event. Often the last line of defence lies with front-line individuals (represented in blue), in our case vets and VNs.
It is all too easy to lay the blame for a mistake at the door of the (blue) individuals who superficially appeared to “cause” the error. Perhaps as vets and VNs, we even lay this burden of ultimate responsibility on ourselves – “it was my bad decision, my surgical error, my poor communication”. But we can see from the diagrams above that human error is not as straightforward as reprimanding an individual and telling them to “do better next time”.
While there is no excuse for negligence, recklessness or sabotage, it is fair to say that in the vast majority of cases, error in veterinary practice is not as simple as a bad vet or nurse making a mistake. Human error is almost always tied up with multiple layers of systems error which can be harder to unpick than simply laying blame on an individual. We all have the potential to make errors, no matter how highly trained we are, and if we can recognise this, we can establish systems to minimise such risk, seeking out the holes in our systems where a hazard could get through.
What if we could put systems in place that make it easy to get things right and hard to get things wrong?
| Take the example of counting swabs in and out of a surgery. “We did count the swabs after we spayed Lola… didn’t we?” What are the holes in the system that could result in a swab being let in and how could the holes be closed? Making sure you communicate well, ensure everyone feels able to speak up and possibly using a checklist are examples of ways to prevent an error from occurring (Figure 3) |
| Take the everyday example of a lump removal. A mass was disposed of instead of being sent for histopathology. What are the latent and active holes in the system that could result in this error occurring (Figure 4) and how could the holes be closed? Whilst it is easy to pick up the active failure – the team member failing to send the mass away – latent failures are those which lie dormant within the systems in your practice and predispose to an error occurring: many small steps culminating in error. |
being made. Identifying these and putting systems in place to avoid them is key to avoid error
Be aware that some failures or “holes” are easier to pick up than others. Active failures are the front-line acts which we see causing an adverse event; latent conditions often lie unseen until they precipitate an error. To reduce error, we must look at the systems we use as well as ourselves or we are walking a very fine line between safe practice and a mistake occurring. In a safety-critical industry such as our own, let’s look at “the why behind the what or who” of an error or a near-miss, and make our profession a safer place for all patients under our care.
Where are the holes in the cheese in your practice? What could you do to close them?
