To Err is Human

Medical mistakes will happen, and how you handle them is important for your clinics culture. Learn from Chief Medical Officer Shana O'Marra, DVM, DACVECC, about minimizing shame and improving clinic culture when it comes to medical errors.

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Humans are fallible. Humans make mistakes. And humans are at the core of veterinary medicine. That means that if we engage in the practice of caring for animals, errors will occur. That error might be getting client information wrong, misinterpreting a blood test, giving the wrong drug or the wrong dose. How we respond to those mistakes determines whether they are opportunities for positive change, or whether they are incidents that traumatize the individual, degrade our relationships with our clients and colleagues, and leave the clinic open to repeating the same mistake.

Medical errors are estimated to be the third leading cause of death for hospitalized humans, with over 250,000 human deaths per year attributed to medical error¹. In the veterinary world, a multicenter study examining medical errors in academic and non-academic institutions found that errors occurred in roughly 5 out of 1,000 veterinary patients². A JAVMA survey study found that 73% of veterinarians have had a case where a medical error or near miss occurred³. Medical errors occur everywhere that medicine is practiced, and veterinary medicine is no exception.

Back in the 80s, the approach to medical errors was to name and shame. If someone made a medical error, they were disciplined or fired. So essentially the approach was that human who made the error was eliminated from the situation – treated as if they were disposable. Then do you think the medical errors stopped? Of course not. But it did lead to complacency. If blame is placed solely on the person involved in the error, then there is no moral obligation to look at the context the error occurred in. Hospitals could have systems that promoted errors and bear no responsibility for it. When we attribute all of the risk for errors to individual behavior, it makes it very easy for colleagues to dismiss the fact that the same error could occur to them. This leads to false confidence that only feeds into the risk of that same error happening again.

In a shame and blame culture, do you think the individual who made the error is able to learn and grow from their mistake? Shame is an incredibly hard thing to overcome, and having personal shame compounded by external public shaming is devastating. That JAVMA study referenced earlier found that the majority of veterinarians that experienced a medical error reported a detrimental effect on their mental health. Apart from the personal impact, the feeling of shame has a severe detrimental impact on learning, suggesting that not only is shaming inappropriate in the context of a medical error, it could even contribute to more errors⁴. In order to have more productive response to medical errors, the concept of “just culture” has been adopted in many human hospitals⁵. A just culture acknowledges the context in which an error occurred. Human nature is such that we will never be perfect, and our systems MUST be designed to account for that. We can easily adopt this approach in our own veterinary clinics.

 

A simplified version of just culture model classifies errors into 3 basic categories:

1. Human error

Response: Support the person who made the error and examine and improve the system in which the error occurred.

Supporting the individual who made the error is not always our first instinct. I would like to make the argument that it should be. Learning cannot occur from a place of shame, and someone who has experienced punitive consequences from a mistake is less likely to speak up when they are unsure of something in the future. We need to have compassion for our colleagues and understand that we may have made the exact same error. More importantly, we need to encourage self-compassion in the individual who made the error. Think back to those vets who I talked about who experienced serious harm to their mental health. What purpose does that anguish serve? Punishment will not prevent that individual from future errors, nor will it prevent others from having the same lapse.

We need to anticipate that our human colleagues will make mistakes. When they occur, the systems that allowed them to occur should be improved to prevent future errors caused by human fallibility. Improvements in the system might be things like decreasing work interruptions, eliminating points of confusion, checklists and reinforcing single points of failure. I invite everyone to take a hard look at a patient’s journey through the hospital and identify points where a moment’s distraction could cause serious consequences. What can you do to provide redundancy or remove distraction at each point?

 

2. At risk behavior

Response: Coach the individual and examine pressures toward unsafe behavior.

At risk behavior references behavior that disregards usual safety measures. The correct action to take is to examine the reasons why the individual took the shortcut and to coach the individual on the importance of the skipped steps. If that individual skipped steps, then it is extremely likely that others are doing the same. The goal here is to remove the reward for bypassing safety measures and ensure that everyone understands the reason for those measures.

 

3. Reckless behavior

Response: Discipline +/- legal action if indicated.

Reckless behavior refers to blatant disregard of possible or likely harm. This may be an individual who continues their at risk behavior despite being coached on the importance of safety measures, an individual who makes decisions under the influences of alcohol or other substances, or any other reckless or malicious behavior. This is the instance where discipline is indicated.

 

 

Resources

  1. Just culture: balancing safety and accountability. (2013). Choice Reviews Online, 50(06), 50-3197-50-3197. doi: 10.5860/choice.50-3197

  2. Wallis, J., Fletcher, D., Bentley, A., & Ludders, J. (2019). Medical Errors Cause Harm in Veterinary Hospitals. Frontiers In Veterinary Science, 6. doi: 10.3389/fvets.2019.00012

  3. Kogan, L., Rishniw, M., Hellyer, P., & Schoenfeld-Tacher, R. (2018). Veterinarians' experiences with near misses and adverse events. Journal Of The American Veterinary Medical Association, 252(5), 586-595. doi: 10.2460/javma.252.5.586

  4. Bond, M. (2009). Exposing Shame and Its Effect on Clinical Nursing Education. Journal Of Nursing Education, 48(3), 132-140. doi: 10.3928/01484834-20090301-02

  5. Just culture: balancing safety and accountability. (2013). Choice Reviews Online, 50(06), 50-3197-50-3197. doi: 10.5860/choice.50-3197

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