Medical error has been defined as an unintended act (either of omission or commission) or one that does not achieve its intended outcome (Leape 1994), the failure of a planned action to be completed as intended (an error of execution), the use of a wrong plan to achieve an aim (an error of planning) (Reason 2001), or a deviation from the process of care that may or may not cause harm to the patient (Groger, Bohnen 2005). Medical errors are a fact of medical practice and have been suggested to be the 3rd most common cause of human death in the US (Makary, Daniel 2016).
There is not a large amount of literature regarding errors in veterinary practice. Wallis et al. (2019) found that drug errors and failures of communication were the most commonly reported errors in veterinary specialist practice, with 8% of errors resulting in permanent patient harm or death. Obviously medical error is something we want to avoid, the consequences for the patient can be huge, but we also need to consider how to deal with a medical error once it has occurred. Dealing effectively with medical errors can lead to a positive outcome. It can decrease the likelihood of the error occurring again, improve the relationship with owners of affected animals, and also decrease the likelihood of negative effects on staff members involved.
Decreasing Likelihood of Medical Error Recurrence
Effective medical error reviews and morbidity and mortality rounds can allow understanding of the reasons why an error may have occurred. Once these are understood, this allows measures to be put in place to decrease the likelihood of the error occurring again. These will be discussed in another lecture.
Management of Clients
Severe damage can occur to veterinary practice reputation and client distress can be markedly elevated if a medical error is not communicated and handled effectively. Rapid disclosure of medical errors to clients is vital and apologies should be made. McLennan et al. (2014) make a valid point that these apologies must be genuine and heartfelt, with apologies being made purely because of management edict being recognised by clients as inauthentic and causing both client and healthcare worker dissatisfaction.
Honesty is vital and a clear explanation to owners of what occurred, why it is thought it was likely it occurred and the investigation that will be performed will all help mitigate the upset that results from a medical error. Following up later with the results of the investigation and changes that will be made as a result will be reassuring to clients that the likelihood of a similar error occurring again will be minimised. Obviously, many clients are understandably extremely upset when an error occurs and initial conversations, particularly, can be heated and very stressful. Having a client liaison team member (ideally, someone who was not involved in the incident) working with the veterinary team and being present at discussions can be invaluable, in providing direction to discussions, to help mediate and also to provide emotional support to the veterinary staff member involved.
Management of Medical Personnel Involved
Staff responses to being involved in medical error vary, but it is recognised that there can be components of post-traumatic stress disorder seen in some people. Stehman et al. (2019) describe ‘Second Victim Syndrome’ which embodies the psychological trauma healthcare workers suffer from involvement in an adverse event. They describe how society sets a ‘zero-mistake’ standard for physicians, meaning that those that make mistakes do not have healthy ways to cope. They also discuss how not being supported by one’s own hospital or organisation can exacerbate this second victim syndrome. It should be noted that ‘second victim syndrome’ is a controversial term and it is worried that its use can cause passivity in healthcare professionals who make errors as well as decrease the focus on the ‘genuine victims’ with medical error (Clarkson et al. 2019).
The severity of the impact of making an error should be recognised though, with Stehman et al. (2019) reporting that it can increase the risk of burnout and suicide. And with burnout being a contributory factor to medical errors, a possible self-perpetuating cycle can be recognised. Burlison et al. (2017) reported that 10.3% of potential second victim healthcare workers responding to their survey stated that they had experienced physical distress due to the event and related absenteeism had occurred in 7.1% people. Burlison et al. (2017) report that the most desired outcome for second victims was for ‘a respected peer to discuss the details of what happened.’ The ASSIST ME model (HSE 2013) has been described to help deal with affected staff members:
A: Acknowledge the event and Assess its impact on the staff member
S: Sorry, express regret for their experience
S: Story, allow them to tell you what happened and Share their experience
I: Inquire, encourage them to ask questions and provide Information
S: Support and Solutions, both formal and informal emotional and practical support
T: Travel, provide continuing support going forwards over time
M: Maintain contact, Monitor progress
E: End, reach a stage of closure and Evaluate, review the support given
Dealing with errors well can make a huge difference to your clients and your staff, it is worth investing the time and effort to make sure you do as well as you can.
References
1. Burlison JD, Scott SD, Browne EK, et al. The second victim experience and support tool: validation of an organizational resource for assessing second victim effects and the quality of support resources. J Patient Saf. 2017;13:93–102.
2. Clarkson MD, Haskell H, Hemmelgarn C, et al. Abandon the term “second victim.” BMJ. 2019;364:1233.
3. Grober ED, Bohnen JM. Defining medical error. Can J Surg. 2005;48:39–44.
4. HSE (2013). Supporting staff following an adverse event. www.bcm.edu/sites/default/files/2018/66/assist-me-model.pdf accessed 12th January 2022
5. Leape LL. Error in medicine. JAMA. 1994;272:1851–7.
6. Makary M, Daniel M. Medical error—the third leading cause of death in the US. BMJ. 2016;353.
7. McLennan S, Walker S, Rich LE. Should healthcare providers be forced to apologise after things go wrong? J Bioeth Inq. 2014;11:431–5.
8. Reason JT. Understanding adverse events: the human factor. In: Vincent C, ed. Clinical Risk Management: Enhancing Patient Safety. London: BMJ Books; 2001:9–30.
9. Stehman CR, Testo Z, Gershaw RS, et al. Burnout, drop out, suicide: physician loss in emergency medicine, Part I. West J Emerg Med. 2019;20:485–94.
10. Wallis J, Fletcher D, Bentley A, et al. Medical errors cause harm in veterinary hospitals. Frontiers in Veterinary Science. 2019;6:12.