Intensive care units in small animal hospitals will have a variety of patients. Depending on the hospital structure the ICU might have any patient where there is any concern of a problem arising, e.g., brachycephalic breed or a patient on seizure watch, which might require limited interventions and plans, to patients which require multiple interventions and treatments by the patient care team, such as those on mechanical ventilation, peritoneal dialysis, or patients with stage III tetanus. It is logical that the more interventions that you and your team have with a patient the more likely a mistake will occur, even if the error/mistake rate is 1%, when a mechanical ventilation patient would have over 100 interventions in a 24 hour period it is likely that a mistake or error will happen. It is likely that the majority of these errors will not lead to patient harm, though it is important to recognise when one occurs so that other team members can learn from them and attempt to put systems in place that minimise these errors in the future. Some of the recent human literature has included any intervention that did not lead to a successful outcome as an error, and that is probably responsible for the perceived medical error epidemic, rather than known complications.

There are a variety of ways in which you can characterise mistakes:

• Active errors
• Adverse event
• Confirmation bias
• Human error
• Lapse
• Latent error
• Near miss
• Omissions
• Redundancy
• Resilience
• Safety culture
• Slips
• System safety

There can also be confounding factors:

• Distractions and interruptions
• Fatigue
• Stress

These will not be fully explained in these notes and I would suggest the following website for further definitions (https://chfg.org/).

Regardless of the errors that are occurring you need some system to capture them, an error recording system, whether that is bespoke or off the shelf (VetSafe, from the Veterinary Defence Society). The importance is in whatever system that is used, you are trying to work out what happened, it is not a witch hunt and you are not going to blame anyone - you need to have a no blame culture in order to actually find out the problems that you have. There are common problems and problems that you are likely to have worked out, though there are always going to be new issues arising whether it is from a new piece of equipment or a new drug.

The following are things to consider, though certainly not exhaustive.

Communication

Poor, lack of, or misunderstood communication can be linked to the majority of errors in large workforces and it is important to consider five aspects of every communication: who, when, where, how, and what?

• Who? Who needs to be involved in the communication, who are you trying to communicate with?
• When? For example, patient handover rounds should be at a fixed time (and start promptly)
• Where? Close to or in the ICU where everyone can be present
• How? Two-way communication using a formal structure - SBAR
• What? Written notes and two-way communication

Listening is a complex skill and we can understand many more words spoken per minute than the speed of normal conversations. We often think that we are listening when we are really just thinking of what we are going to say next. It is important to be patient when listening, ask questions and paraphase, making eye contact with the person that you are speaking to and using positive body language, you should not debate what is being spoken in your mind, try to change the subject, interrupt, finish what people are saying, tune out, or think about what else needs to be done.

For example, patient handover you could consider a standard way of presenting cases such as SBAR (Situation, Background, Assessment, Recommendations), prior to the first patient it’s good to have introductions for all the members present in rounds, as not everyone is likely to know each person or their role. It is prudent as well to make sure that the person(s) finishing their shift informs if there are treatments/interventions that have not been performed for whatever reason so that the starting team knows that needs to be done first.

Medication Errors

These are still very common in human medicine regardless of the systems that are in place. It could be: an active error, such as prescribing something that the patient has a known allergy to; or a human error, such as a 10x overdose (reading mg instead of mcg); a latent error, such as administering the wrong drug as it has a similar name; a lapse, forgetting a current medication that the patient is on; a near miss, remembering at patient discharge that they should be going home with a medication that hasn’t been prescribed; omissions, failing to prescribe a medication that is known to improve outcome.

It is important that handwriting or electronic records are clear and cannot be misunderstood as well as using the same way throughout the hospital to prescribe, for example total dose, or mg/kg. Drug names are usually preferred compared to trade names, though it should be consistent.

Teamwork

There are a number of considerations to improve teamwork:

• Communication
• Followership
• Non- technical skills
• Shared mental models
• Team culture
• Team leadership
• Teamwork

All of these can be worked upon. Simulation can be a tool that is used bring the team together to perform a task, whether that is CPR training or how to manage a trauma case, the challenge is finding the time for these exercises, though they can have profound effects on the team culture.

Mental Health

Fatigue and stress are often cited as contributory factors, we are human after all. What we need to do is recognise these in ourselves and know when to ask for help at the workplace when you are affected, for example if you are tired asking someone to check your drug calculation. You need to bring your best self to work and it is not easy day in, day out. Though any improvements in your own health and wellbeing are going to have benefits on your work. It is making sure that you carve out enough time to look after yourself, and that is going to be different for everyone.

How Can You Implement Change?

You need to think about what does good look like. An environment where constructive challenge is viewed positively and rewarded, where staff feel empowered to prioritise safety, that clients are seen as part of the safety team, where procedures are reviewed on the basis of what is right, not who is right (everyone should adopt the best practice), where task priority is maintained in challenging work settings (for example staff to reduce distractions and resist pressure to attend competing demands - keep patient handover quiet, do not interrupt someone who is calculating medicine for doses).

There is a lot of information on patient safety and medical errors, though is it important to remember to learn lessons from previous incidents and use them to improve practice. Think about practical ways to learn about improving communication using briefing and debriefing techniques. Make it possible that potentially unsafe behaviours are challenged by anyone in the team and that situations where error is more likely are recognised and conditions created to reduce risks. We all have a role in patient safety.

References

References are available on request.