Errors in practice: Who is to blame?
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NHS consultant Anne Pullyblank (pictured) and veterinary surgeon Catherine Oxtoby stressed the need for a shift in culture.
'The buck shouldn't stop with the surgeon; it should be shared among the team'. This was the key take-home message from the opening session on patient safety at this year's BVA Congress.
NHS consultant Anne Pullyblank and veterinary surgeon Catherine Oxtoby stressed the need for a shift in culture - away from blame and towards systems that can mitigate the risk of harm to patients.
The short term memory is capable of holding only five to seven pieces of information. We get tired, and we have a limited ability to multi-task. In short, we are human, and we are going to make mistakes. It shouldn't be about blame, it should be about systems.
One such intervention that has garnered increasing attention in the veterinary profession is the patient safety checklist. But they are not a fail-safe solution to human error, Anne Pullyblank warned delegates, and are only as good as the level of engagement staff have with them.
Patient safety and mistakes in surgery are a well publicised issue in human medicine, with research suggesting 10.8 per cent of patients experience an adverse event during hospital admission, a third of which lead to severe disability or death. Around half of these are avoidable.
Pullyblank outlined some of the potential risk factors: our cognitive limitations; home/work related stressors; pattern recognition (we see what we expect to see, which can lead to mix-ups between similarly-named drugs); and hierarchy issues where students or more junior members of staff are unwilling or unable to question their seniors, or are not listened to when they do.
Catherine Oxtoby drew attention to the tendency of vets to blame themselves for all errors, feeling that regardless of their direct involvement, 'the buck stops with them'. But it shouldn't. Human error will always occur and we need to recognise our own limitations. In order to prevent mistakes happening again, systems involving the whole team must be implemented.
Checklists have the ability to ensure the whole team has full situational awareness - they should be read out loud and checked by another person. In addition to avoiding rare and serious errors, they are about quality control, helping to provide the full bundle of care.
But as Pullyblank demonstrated when she shared examples of her own mistakes, you can still have a 'never event', even when a checklist is used. It is unwise to add to checklists each time a mistake occurs - the list should be composed of the essentials; it should not be a burdensome box-ticking exercise.
Barriers to checklists are poor uptake, lack of understanding on how to use them, reluctance of staff to change their habits, professional autonomy and hierarchy. In order to make them work, we need leadership and better training in non clinical skills. In some cases, technology could have the answer to reducing errors, Pullyblank added.
What came out of the discussions is that we - in both the veterinary and human medical profession - do not train people to communicate effectively and further training in this area is needed.
The University of Bristol is currently working to acquire funding for a bespoke veterinary checklist, although Pullyblank highlighted the positives in individual practices being able to modify the list to suit their needs.
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