In this session we will explore evidence-based tips and tools to improve patient safety in the ultra-adaptive, veterinary, emergency care setting.

Veterinary healthcare is described as a complex sociotechnical system; it is dynamic, unstable, and constantly changing, with multiple factors which must be considered when problem solving. The emergency and critical care setting epitomises this type of system and must strive for excellent patient safety whilst remaining ultra-adaptive. By considering the type and nature of work that is carried out in any setting, it is possible to fully consider safety and therefore implement effective strategies to prevent adverse events from occurring and improve the efficiency and performance of teams whilst ensuring their health and wellbeing are attended too.

By seeking to understand the lessons learned by other safety-critical industries such as aviation, nuclear power, and healthcare, we can successfully translate them to provide effective solutions to patient safety challenges.

For all veterinary professionals the desired result of their work is likely to be excellent patient outcomes. To achieve this, it is vital to look beyond excellence in clinical skills and knowledge and consider the nontechnical or non-clinical skills required, the health and wellbeing of the team, the systems and process which support the work, and the culture of the team and organisation.

Within veterinary teams it is commonplace to work with different people, different combinations of people, or perform different tasks/roles within your team, and this may vary from day to day. This is a concept known as teaming which is collaboration and coordination to get important things done without the luxury of stable membership (Edmondson). Professor Amy Edmondson has considered this extensively in her research and suggests three things that we can all do to team more effectively:

• Let go of the need to have all the answers
• Make time to connect
• Be curious and welcome curiosity

Implementing Edmondson’s advice consistently is shown to improve teamwork, collaboration, and efficiency and begins with a briefing at the start of every shift.

To ensure good teamwork, leadership, and communication, and to guarantee that patient safety is maintained, the Clinical Human Factors Group advises that the whole team is briefed, even if rapid and short. Leaders should encourage psychological safety by being open and inclusive; asking questions first and leading second, and should encourage their team to speak up with questions, concerns, and feedback (CHFG 2020). During the briefing, the team should work together to consider any challenges that they might face and plan the shift ahead.

When planning the shift, HALT (VetLed 2022) should be implemented, and breaks should be planned for all members of the team. Those breaks should then be prioritised, and team members should support each other in pausing to rest, eat, drink, alleviate stress, and recognise how they are feeling. It may also be advantageous to plan a debrief for the end of the shift to enable the team to learn from experiences and maintain wellbeing. By using a hot debrief framework such as STOP₅ (Walker et al. 2020), checking everyone is ok, summarising the shift or a patient’s journey, and the things that went well whilst recognising areas where learning or improvement might be required, the team can begin to make sense of what happened. This is particularly important after challenging or upsetting events and reduces the incidence of psychological harm, moral injury, or becoming second victims. Cold debriefs (held in the subsequent days or weeks) such as learning discussions and significant event audits can also be powerful aids in ensuring continuous improvement and supporting a learning culture.

Throughout the emergency shift, it is essential to consider tools, care bundles, and protocols which can be implemented to ‘make it easy to do the right thing.’ These might include the five rights of medication administration which are recommended to reduce medication errors and harm and asks anyone administering medication to check that they have the right patient, right drug, right dose, right route, and the right time of administration before they give the medication. Within human healthcare, checklists for central line insertion have been shown to reduce central line-associated infections, and therefore, veterinary ICU placement checklists have been developed to use when central lines, PICC lines, arterial catheters, chest drains, and oesophageal tubes are placed.

It is also important to consider the impact that communication can have on outcomes. The Joint Commission reported that in the United States, communication was a root cause of nearly 70% of adverse events reported to the organization between 1995 and 2005 (Murphy, Dunn 2010). To improve communication within teams, several small but highly effective changes have been shown to reduce error. The use of closed-loop communication (a three-step communication process which is based on verbal feedback to ensure proper team understanding of a meaningful message [Salik, Ankhurst, 2020]), knowing the first names of people in the team, and using appropriate assertiveness are three such easy to implement strategies which improve communication, flatten hierarchy, reduce confusion, and improve moral.

References

1.  Edmondson AC, Schein EH. Teaming: How Organizations Learn, Innovate, and Compete in the Knowledge Economy. 2012.

2.  Clinical Human Factors Group. Key human factors messages—when working under pressure. 2020. Available at: https://chfg.org/key-human-factors-messages-to-support-the-nhs and https://www.vetled.co.uk/halt.

3.  Murphy JG, Dunn WF. Medical errors and poor communication. Chest. 2010;138(6):1292–1293.

4.  Salik I, Ashurst JV. Closed loop communication training in medical simulation. In: StatPearls. StatPearls Publishing; 2021.

5.  Walker CA, McGregor L, Taylor C, Robinson S. STOP₅: a hot debrief model for resuscitation cases in the emergency department. Clinical and Experimental Emergency Medicine. 2020;7(4):259.