We all are familiar with Sully Sullenberger, the pilot who was the captain of the flight that successfully landed on the Hudson River – “The Miracle on the Hudson”. Captain Sullenberger has become involved in the conversations surrounding medical errors and made an observation that will forever stick in many of our minds. “ There are over 200,000 preventable deaths each year including medical errors, which are mostly system failures and healthcare associated conditions like hospital – acquired infections. That is the equivalent of 3 airliners crashing every day without survivors….that would not be tolerated in my (aviation) world.”
Just stop and think about that comment for a moment…. If each of us stopped and thought about the fact that even though there are thousands of flights every single day in the United States, how many of us would really get on a plane and fly if we gave considerable thought to the idea that there would be 3 planes that would crash that day and there would be no one that survived. I think most of us would be doing a tremendous amount of driving.
Another amazing fact is that across the United States, to become a certified cosmetologist, classes and training in excess of 1000 hours is required, although, to become a certified nurses aide, the required training is 75-100 hours. Again, just stop and think about that disparity for a moment.
As veterinary medical professionals, we should take the information above and then take into consideration the fact that we have absolutely no idea how many errors occur in veterinary medicine everyday. How mind boggling is it that we have not stopped for a moment to consider a way to track this information and as a result of that, developed ways to reduce and/or eliminate many of the errors that occur in veterinary medicine today.
One of the challenges in presenting this material is the fact that it is very difficult to know how often medical errors occur in the veterinary medicine profession. An article written by Joel Aleccia in 2010 stated that the AVMA does not collect statistics on veterinary malpractice, according to Adrian Hochstadt assistant director of state legislative and regulatory affairs for the American Veterinary Medical Association, which represents about 80,000 veterinarians. Hochstadt was quoted in the article as saying “ I guess I don’t agree that there is a lot of malpractice out there. If there are negligent doctors- and there are probably a few in every system- if it’s a big problem, it would have been addressed by legislation.”
Let’s think about that for a minute. We all know mistakes happen but if we don’t track those mistakes and work for a solution are we doing all we can to better our profession? What errors specifically occur in veterinary medicine, and how to prevent errors in the practice of veterinary medicine are important concepts for all practitioners to understand. One study published in 2004 in the Journal of Veterinary Record found that 78% of recent graduates of programs in Scotland and England surveyed admitted to making a mistake that could have had significant consequences. It’s hard to say if we can apply those statistics to the overall veterinary profession, but it’s pretty clear from looking at the statistics in human medicine that mistakes are significant, costly and potentially deadly.
We will examine the healthcare system in the United States and use the concept of inter-professional education as defined by the Institute of Medicine to carry-over techniques to the veterinary medicine field in reducing medical errors. We will also discuss how to perform a root cause analysis (RCA) to reduce errors in the veterinary medicine field.
History of Medical Errors in the United States Healthcare System and Comparisons to Veterinary Medicine
The history of medical errors is a rather short one as there was very little knowledge of medical errors until 1999. Through this course, we will start from the beginning and bring the events and progress right up to the present. To get started, let’s make sure we are all on the same page. What is the definition of a Medical Error? According to the Institute of Medicine, “Medical errors can be defined as the failure of a planned action to be completed as intended or the use of the wrong plan to achieve an aim.”
Before we delve into the history of medical errors, let’s take a moment to look at factors that increase the risk of errors. J.T. Reason provided the following factors that we should keep in mind during the duration of this course. We have also added examples that might lead you to identify with one or more of these factors:
- Fatigue – working double shifts and 12-hour shifts increase the fatigue level in humans. It has been documented that reducing work hours significantly reduces error rates.
- Alcohol and/or other drugs – easy access and high stress levels have led to substance abuse among clinicians.
- Illness – reporting to work when ill increases the chance of infecting patients.
- Inattention/distraction – treating multiple patients can lead to a lack of concentration.
- Emotional status – everyone struggles to block out their own problems, which can lead to distraction and errors.
- Unfamiliar situations or problems – clinicians covering for a co-worker may lead to issues in treatment.
- Equipment design flaws
- Inadequate labeling or instructions – without proper instructions on equipment, misuse can lead to errors. Medications can also have improper labeling that can lead to medical errors.
- Communication problems – lack of communication, written, verbal or electronic between clinicians and/or patients can lead to problems.
- Hard-to-read handwriting – Electronic medical records and electronic medication orders have already greatly reduced this issue.
The laser-focused attention on medical errors/sentinel events in the U.S. healthcare system began in 1999, when the Institute of Medicine (IOM) released the first of two reports that were part of a series of reports known as the “Quality of Health Care in America” project. These two reports (IOM-1 and IOM-2) have changed the way the public, the government and healthcare systems think about patient safety and the quality of care. “To Err is Human: Building a Safer Health System” (IOM-1), was released in September of 1999 and was focused on the specific area of medical errors in the hospital based setting.
As we move through the course, it will become apparent that many of the factors that cause medical errors presented above in the human world, are the same as the factors that affect the manifestation of errors in the veterinary medical world.
Since the AVMA does not track medical errors or malpractice suits it’s hard to come up with an accurate number of how often medical errors occur in veterinary medicine. An internet search referred to one article “Survey of mistakes made by recent veterinary graduates” by R. J. Mellanby, M. E. Herrtage that explored the incidence of veterinary medical errors. A questionnaire was sent out in November 2002 to all the veterinary graduates of the Universities of Bristol, Edinburgh, Glasgow, London and Liverpool in 2001. Four hundred and two questionnaires were sent out and 108 questionnaires were returned completed. Since starting work, 78% of the respondents stated that they had made a mistake, defined as “an erroneous act or omission resulting in a less than optimal or potentially adverse outcome for a patient.” In many cases, these mistakes had a considerable emotional impact on the veterinarians involved.
This survey was designed to evaluate the incidence and types of mistakes made by new graduates of veterinary medicine in the early part of their careers.
106 veterinarians replied to the question “Do you work unsupervised?”
Nearly always 1
So, 83% of respondents frequently or always worked without supervision.
The next question was “How much support is available to you from other vets in the practice?”
Never available 2
Occasionally available 14
Frequently available 37
Always available 46
Frequently/always available 3
Occasionally/frequently available 2
Nearly always available 1
Available except on weekends 1
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?” had 78% of the respondents reply that they had made a mistake. Out of those responses. 73 of the respondents gave further details about the mistake. 54 of them felt “that lack of experience was a contributing factor, 26 that lack of time was a factor, 19 that lack of supervision was a factor, 15 that a communication problem with colleagues was a factor, 12 that a communication problem with owners was a factor, 11 that a lack of information support was a factor, and 9 that inadequate equipment was a factor in their mistakes.”
Of the 73 respondents, only 43 had discussed the error with the animal’s owner. Three replied that their employer or a colleague had discussed the mistake with the owner, and 27 replied that they had not discussed the mistake with the owner. Sixty-eight of the respondents had indicated that they discussed the error with either their friends, family or colleagues. The impact of these mistakes on the veterinarian included guilt, decreased confidence, stress and loss of sleep.
Below is the list of the 73 mistakes made by the veterinarians that responded to the survey. Totals listed include errors in dogs, cats, horse, cattle, exotics, and unspecified animals.
Nature of Mistake Total
Appropriate diagnostic test not performed 13
Inappropriate diagnostic test performed 3
Incorrect interpretation of appropriate diagnostic test 4
Incorrect interpretation of radiograph 3
Surgical mistake during neutering 6
Surgical mistake during other procedures 12
Administration of inappropriate drugs/medical therapy 17
Failure to administer appropriate drugs 1
Failure to undertake appropriate surgical treatment 1
Delay in administering appropriate drugs/surgical treatment 2
Appropriate drugs given to wrong animal 1
Incorrect prognosis given to owner 1
Mistake made during sedation/anesthesia 7
Mistake made during certification 1
Mistake made during euthanasia 1
The mistakes were highest on dogs at 27, followed by cats 16, cattle 11, horses 11, exotics 6, and 2 unspecified species. It is unknown if dogs were most commonly affected because the veterinarians were treating more dogs than any other species, so no conclusion can be drawn in this regard. According to Mellanby & Herrtage, “The most common mistakes involved the failure to perform an appropriate diagnostic test, surgical mistakes during non-neutering procedures, and the administration of inappropriate drugs or medical treatment.”
This survey highlighted the fact that a large number of veterinarians that recently graduated from school worked with little supervision and that many veterinarians beginning their careers in practice do not always have access to other veterinarians for clinical support and mentorship. According to Mellanby and Heritage “the results of this survey indicate that a significant number of recent graduates make mistakes in their first 18 months in practice.”
The healthcare system in the United States has been more proactive than the veterinary profession in developing ways to reduce the frequency of errors through tracking and accountability. So let’s review a few of the actions taken when the problem of medical errors in the human world came under the spotlight.
The landmark report (IOM-1) revealed that 98,000 people die each year as a result of medical errors. The report estimated between $18 and $29 billion dollars were spent in medical care due to these errors. IOM-1 does not “point the finger” at any particular person or group, but rather refers to the faulty systems, processes, and conditions that lead people to make mistakes or fail to prevent them.
IOM -1 brought with it’s staggering numbers of errors and expense, great controversy as to the reliability of the information. Two articles published in JAMA (Journal of American Medical Association) on July 5, 2000 represented polar opposite thoughts. McDonald and others suggested that the number of errors reported was grossly exaggerated. At the same time, Leape, a recognized leader in the field believed the numbers might be underestimated and that the burden brought on by medical errors was far more staggering than suggested.
To better discuss issues related to medical errors, the IOM- 1 report developed a category system for errors that is presented below:
- Diagnostic errors
- Error or delay in diagnosis
- Failure to employ indicated tests
- Use of outdated tests or therapy
- Failure to act on results of monitoring or testing
- Error in the performance of an operation, procedure, or test
- Error in administering the treatment
- Error in the dose or method of using a drug
- Avoidable delay in treatment or in responding to an abnormal test
- Inappropriate (not indicated) care
- Failure to provide prophylactic treatment
- Inadequate monitoring or follow-up treatment
- Failure of communication
- Equipment failure
- Other system failures
The greatest percentage of medical errors reported in IOM – 1, were medication errors. As can be expected, in 1999, when almost 100 percent of all prescriptions were handwritten, a significant number of errors occurred due to the inability of the pharmacy staff to correctly interpret the handwriting. Unfortunately, medication errors can occur at any stage of the administration of medication including ordering, transcribing, dispensing, administering, and monitoring. Another sad fact presented in 2000, revealed that 20% of patients were not literate enough to read, understand, and follow their prescription directions, which translated into more medication errors.
As a conclusion to the report, the committee recommended a four-part plan to include:
- Create a “Center for patient safety within the Agency for Healthcare Research and Quality”.
- Establish mandatory and voluntary reporting systems.
- Raise standards and expectations for improvement in safety through the actions of oversight organizations, group purchasers, and professional groups.
- Create safety systems inside healthcare organizations through the implementation of safe practices at the delivery level.
Based on the actions outlined above, it is important that we in the field of veterinary medicine, use this information to assist us to begin to evaluate and develop methods to reduce medical errors.