Building a safety culture in practice - a whole team approach

This is article four in an RCVS Knowledge series of features on patient safety, clinical human factors, and the principles and associated themes of Quality Improvement (QI).

The phone in the prep room at Park Lane Vets is ringing which means someone has an emergency.  ‘It’s going to be a Manic Monday,’ James thinks to himself. He looks up from the scrub sink to check on the cat spay. Good, Andrea, the head nurse has started to clip a neat patch of fur on the animal’s flank. At that moment, Helen, the receptionist, rushes through from the front desk and asks a question to no one in particular. James starts washing his hands a little faster. In his experience, it’s never a good sign to see Helen this early in the morning – she is normally so resourceful.

“J, is it alright to leave Louise looking after the anaesthetic for a minute? The computers have crashed.”

“Err, yep, alright then. But I’m nearly finished, so quickly pl…” James shouts back as Andrea disappears through the prep room door.

He watches Louise, one of the trainees, head down, cleaning the surgical site as she has been taught. The antiseptic is the colour of the Rosé wine he'd enjoyed yesterday, in the last of the summer su….

BANG!

James watches helplessly as the end of the anaesthetic circuit arcs through the air. In an instant - a sickening, dread-filled instant - he knows exactly what has happened. 

Reflecting after the incident occurred

In the days that follow, life at Park Lane Vets slowly got back to normal. Mercifully, the cat lived, but James finds himself re-playing that morning in his mind. Over and over again. Blaming himself: I should never have let Andrea go.  I should have been concentrating - everyone knows that the vet is responsible for their anaesthetic. What an idiot. But later, during a phone call to his old university mate, Fred, he’s reminded of what a wise old lecturer had told him once: You’re only human – don’t expect too much of yourselves.’

Meanwhile, upstairs. Knock, Knock!

“Yes, come in,” Mike, the practice owner says.

Andrea peers round the door to his office and hesitating, walks in.

“Mr Cooper, c, could I have a quick word?” Andrea gives him a brief account of what happened and, because she has recently read an article on Significant Event Auditing (SEA), offers to lead a meeting, so the team can reflect together and share their learnings.

Mike decides to grab the metaphorical bull by the horns and blocks off an hour of consulting time the following week so everyone can attend. He then sends a friendly email to the whole team explaining that he wants to discuss the incident but not to apportion blame. He writes:

“I understand that we all have a responsibility to provide the highest possible standards of care. This includes me! As the owner, while I no longer consult, I have an important role in managing the practice and the clinical side of things. For this reason, I’m really keen to understand what occurred with Marmalade the cat spay, so that we can learn from what happened and put measures in place to minimise the risk of this happening again. But this is not the same thing as saying I want to find out who was at fault! I would like everyone to come along next week so we can explore the events leading up to the incident together. That way I hope to improve our service for future clients and patients.”  

Then he sends Helen a message asking her to divert the phones and to order in a couple of pizzas at the allotted time (“but please make sure at least one of them is vegetarian”). Feeling a surge of enthusiasm, he pulls up the RCVS Knowledge website pages. He thinks, ‘Client and animal-care is better served by openly exploring how we can improve! This is what it’s all about, after all.’

The first step in adopting a safety culture

On the day Andrea starts the meeting off by explaining the central idea behind patient safety: that accidents in practice are more often than not the result of unforeseen circumstances, and very, very, rarely the result of one negligent, or bad person. She goes on to give an overview of something called the ‘Systems Approach’ to Quality Improvement;

“What I mean by this is that we should try to think of the practice as a machine. A machine with many interconnected parts that are designed to help animals. But that machine, or ‘system’ is bound to go wrong occasionally – like last Monday. There is no such thing as a perfect practice! Today we are just going to talk about our machine and think about some safety measures we can put in place to improve it. Let’s talk about what happened and come up with a new protocol.”

Andrea goes on to explain that by doing this for similar events in the future, they can build a ‘safety culture’ where, for the benefit of patients, everyone routinely talks about mistakes and near-misses. As they start to discuss the accident, Andrea feels good – we could really change things here, she thinks to herself…

Implementing changes for continuous improvement

Building a culture of safety in practice - like the one Andrea mentions in her first SEA meeting - can sound like an almost insurmountable challenge. And, when there are so many other things to think about - clients to call, forms to fill in and animals to treat - it can be easy at times to not think too long, or too hard about it. However, the building blocks of a safety culture are actually relatively easy to incorporate into our working lives, and close at hand. They are also key to quality improvement in practice¹. The following list isn’t exhaustive, and more in-depth articles can be found elsewhere, but by sticking to it you will be helping to bolster care quality in your practice:

• Use the ‘Systems Approach’ when considering any adverse event – never seek to unfairly blame individuals, including yourself, when accidents occur. Actively thinking about the underlying causes of mistakes and near-misses is a powerful technique to improve the care you and your team provide. It also helps employee psychological well-being and engagement^2,3,4.

• Effective leadership: support staff, encourage open discussion of accidents, and unambiguously place patient safety high on the practice’s list of priorities^5,6.

• Make use of a reporting structure so that the practice can learn more about itself. If you don’t have one, think about ways to encourage event reporting, for example, by making the process less daunting (listen to the podcast on Significant Event Auditing by Alice Bird for some great tips).

• You also could use Vetsafe, which is a free anonymous incident reporting tool managed by the Veterinary Defence Society.

• Make clear to the team the types of accidents that should be reported and how they should be recorded⁷. Once these have been reported, encourage the team to follow the Significant Event Audit process shortly after, so that systems can be put in place to avoid the accident happening in the future.

• Make Significant Event Auditing a routine part of practice life¹.

• Empower teams to make changes when they can see a better way⁸.

• Always feedback the results of the SEA to the whole practice team (openness is key)⁷.

In the story earlier, characters used these points as they sought to learn from the incident with the anaesthetic machine - reducing the chance of the same thing happening again to another animal, and to another staff member. Andrea, Mike, James and the rest of the team used valuable, simple-to-follow principles that enabled them to think about a serious incident in a constructive way. A way that has the potential to fix a failing part of their ‘system’ for generations of patients to come. That is what a safety culture is all about.

Discussion point

As we begin 2021, and leave behind a tumultuous 12 months, one new year's resolution that may be worth considering is the way you think about and respond to patient safety accidents. The benefits will be felt not just by patients and clients, but just as importantly, the whole practice team as well. 

Checklist - what you can do next

• A free course to take at your own pace on Significant Event Auditing in practice.
• A quick how-to guide for running significant event audits.
• A handy template to record the results of the significant event audit.
• Find out how to use root cause analysis, the 5 whys, contributory factors checklists and cause and effect diagrams. Using a clinical example you can see how these tools can find the true cause of a significant event in practice and help steer your team towards a safety culture, and away from a blame culture.
• The contributory factors checklist template.
• The cause and effect template.
• A three-minute tutorial on how to use the fishbone diagram.
• All you wanted to know about surgical safety checklists, the RCVS Knowledge’s Surgical Safety Checklist Manual, complete with templates and case examples. A great tool to use to help convince others.
• Use the Rolling Take 5 system to put a quick and straightforward system in place to help keep safety in check. Take a moment before the start and end of the shift to discuss these questions with your team. The discussion can help improve communication between shift teams, to identify areas for improvement, to identify processes that have worked well and flag up required support for the team.
• Vetsafe, the free and anonymous error reporting tool by the VDS.
• An excellent case example for patient safety by Louise Northway RVN, with resources and tips aplenty.
• An article by Alistair Mair on using checklists for patient safety.
• Listen to Alice Bird’s case example on how to run a Significant Event Audit, including top tips to make the process less daunting.
• Listen to Margaret Mary Devaney and Anita Malana give their emotive talk at a veterinary summit on their experience of patient safety in the NHS.
• Listen to Pam Mosedale explain how and why to use checklists in veterinary practice.
• Listen to Lizzie Lockett, CEO of the Royal College of Veterinary Surgeons, talk about making mistakes.

References

¹Chassin, M.R. and Loeb, J.M. (2011) The ongoing quality improvement journey: Next stop, high reliability. Health Affairs, 30 (4), pp. 559–568. https://doi.org/10.1377/hlthaff.2011.0076

²Nieuwenhuijsen, K., Bruinvels, D. and Frings-Dresen, M. (2010) Psychosocial work environment and stress-related disorders, a systematic review. Occupational Medicine, 60 (4), pp. 277–286. https://doi.org/10.1093/occmed/kqq081

³Daugherty Biddison, E.L. et al. (2016) Associations between safety culture and employee engagement over time: a retrospective analysis. BMJ Quality & Safety, 25 (1), pp. 31–37. http://dx.doi.org/10.1136/bmjqs-2014-003910   

⁴Wake, M. and Green, W. (2019) Relationship between employee engagement scores and service quality ratings: analysis of the National Health Service staff survey across 97 acute NHS Trusts in England and concurrent Care Quality Commission outcomes (2012–2016). BMJ Open, 9 (7), e026472. http://dx.doi.org/10.1136/bmjopen-2018-026472

⁵Vogus, T.J. and Sutcliffe, K.M. (2007) The impact of safety organizing, trusted leadership, and care pathways on reported medication errors in hospital nursing units. Medical Care, 45 (10), pp. 997–1002. http://dx.doi.org/10.1097/MLR.0b013e318053674f   

⁶Castel, E.S. et al. (2015) Understanding nurses’ and physicians’ fear of repercussions for reporting errors: clinician characteristics, organization demographics, or leadership factors? BMC Health Services Research, 15:326. https://doi.org/10.1186/s12913-015-0987-9

⁷Evans, S.M. et al. (2006) Attitudes and barriers to incident reporting: a collaborative hospital study. BMJ Quality & Safety, 15 (1), pp. 39–43  http://dx.doi.org/10.1136/qshc.2004.012559  

⁸Sfantou, D. et al. (2017) Importance of leadership style towards quality of care measures in healthcare settings. Healthcare, 5 (4), 73. https://doi.org/10.3390/healthcare5040073

About the author

Mark Turner BVSc MRes MRCVS

Mark graduated from the University of Liverpool in 1996 and in 2017 completed a Masters degree at the RVC investigating patient safety culture in the UK veterinary professions.

The research project investigated contemporary knowledge of patient safety behaviours in practice including significant event reporting and auditing.

He has an interest in the application of patient safety as a tool for improving staff engagement and success. He has written for Vet Times, Companion magazine and appeared as a guest blogger for the BVA/RCVS Vet Futures project.