I made a mistake, what now? - how to deal with errors and embed a learning culture in practice

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

I can’t believe how stupid I have been! It’s awful. I could have killed the poor dog. If the owners complain, I could get struck off! I’m ashamed, upset, horrified. How could that have happened – to me – a reasonably competent vet, 30 years qualified. I have only been working at this practice for four months. What will they think of me? I worry I am getting out of date when I see all the bright younger graduates. Am I still really fit to practise? Morgan, a Collie, came to me for a routine check. He was on Vetmedin®. I prescribed a month’s supply. I must have picked up Vetoryl® by mistake. The next day Mrs Jones phoned in and asked if she could have the usual chewable tablets for Morgan as she could not get the capsules down. Sue, on reception, got Mrs Jones to bring the tablets in. When I saw them, I knew what I had done straight away. The Clinical Director, Stefan, suggested we discuss it as a Significant Event. I was mortified. Now everyone would know just how useless I am.

The cost of medication errors 

An estimated 237 million errors involving medication occur in the NHS annually. These contribute to 1,700 deaths each year (Elliott et al. 2021)¹. Early data on patient safety events from the Veterinary Defence Society’s VetSafe has found that 30% of recorded patient safety events are medication errors (CVS QI Report, 2019)². It is likely that a vet in a first opinion small animal practice prescribes, supplies, and dispenses at least 30 medicines per day. Most of the time, it all goes fine, but there is potential for errors in every step of the process. While not all medicine errors cause harm, those that do can be very upsetting for the owner and lead to a lack of trust in the practice. 

Errors can be financially costly too. For example, in human healthcare Elliott et al. (2021)¹ found that avoidable medicine errors cost the NHS more than £98 million annually to rectify mistakes and manage consequences. 

The person that makes the error is a ‘second victim’ (Wu, 2000)⁴. 

The experience can be devastating for them. Mistakes can lead to a loss of confidence, avoidance of certain situations or types of work, and even leaving the profession. In addition, they can experience long term feelings of fear, distress, self-doubt, physical symptoms, and mental ill-health (Oxtoby and Mossop, 2019)⁵. 

Of course, we want to avoid errors, but mistakes are part of being human. We can use various tools to support our patients and our teams to enable us to use mistakes as learning opportunities. By understanding what led to the event in question, rather than leaping to conclusions and blaming individuals, we can learn about the systems in which we operate, and how we interact within these systems as a team. This way, we can put steps in place to reduce the likelihood of mistakes occurring. 

Tools to use after an error

Hot debrief can be used straight after a serious incident. Stopping for 5 minutes to put the kettle on and talk through the event with the team involved to understand what went well and opportunities to improve. 

Cold debriefs are in-depth reviews held after an event. Different techniques include:  

• Morbidity and Mortality (M&M) meetings are regular meetings to encourage clinical team members to identify harm, report problems, and share lessons to reduce recurrence. 
• Critical incident reviews are for an incident with an unintended or unexpected outcome that did, or could have, led to harm to the patient to identify problems and contributing factors to prevent a recurrence. Not all incidents affecting patient care and the running of the practice are purely clinical, though. 
• Significant Event Audit can be used to review any event that is thought by anyone in the practice to be significant to the care of patients or the conduct of the practice (Pringle, 2009)⁶. 

Whichever of these tools is used the most important thing is that practice teams learn from good and bad outcomes, near misses, examples of excellence and trends in results. 

In the story about Morgan the Collie, the significant event meeting revealed that I had been working nine hours without a proper lunch break when this happened. Denise, the receptionist who had double-checked the tablets, had blamed herself. She hadn’t brought her glasses to work, and the print is so tiny on drug labels. The student nurse, Dianne, had raised the issue of the dispensary being messy. The practice manager thought that having the dispensary arranged alphabetically was not a good idea. All the vets said that similar things had nearly happened to them. This was a mistake that was waiting to happen. I was dreading the significant event meeting, I was in tears and distraught, but the team rallied around me and each other, and we were able to understand why things went wrong, what we could do to avoid it next time, and be supportive of each other – coming out a stronger and safer team.

Discussing events can be very intimidating for those involved. However, practices can take small steps to make the team less daunted by the process by discussing near misses. These can be a great place to start as they will be less influenced by hindsight or outcome bias, so the team may feel safer. There are free, step-by-step resources for running Significant Event Audits available from RCVS Knowledge. If done well, Significant Event Audits should improve patient safety, team working and practice culture.

Luckily, Morgan the Collie was fine. We explained to Mrs Jones that we had changed some of our dispensing procedures. She was happy with this, saying that she didn’t want this to happen to anyone else’s dog. I still feel guilty, but the practice team had a team culture to be proud of. I am so grateful. At my previous practice, it would have been a blame fest! 

Checklist: What can you do next

• Access the free Quality Improvement Boxset, a series of small bite-sized resources where you can learn about Quality Improvement, including how to conduct meetings in practice.
• Delve deeper into performing a Significant Event Audit, RCVS Knowledge's free Significant Event Audit tools and resources include templates, walkthroughs, case examples and a free CPD course.
• Download RCVS Knowledge's Rolling take 5 - Questions to discuss as a team, adapted from the NHS England 'Going home checklist' to help improve communication and identify areas for improvement and support for the team.
• Culture has an important role in patient safety. Have a read of our previous QI feature, Team culture in veterinary practice: Why it's essential for success to discover how.
• Have a read of our previous QI Feature, When it all goes wrong: The importance of debrief, to learn how they can help improve team and individual performance following a significant event.
• Find out how our fictional practice, QI Vets, handles errors and mistakes in their practice. Based on real-life events, these case examples detail how errors were investigated and what processes were put in place to help prevent them reoccurring. 
• Read our real-life case example of how a practice team reacted after a patient escaped while trying to maintain social distancing during COVID -19. This example show how the practice used Significant Event Audit to bring about improvement.
• Visit Second Victim Support to learn more about the stages that second victims experience and download this Second Victim Recovery Graphic, developed by Helen Silver-MacMahon.
• Use this Hot debrief framework, developed by Edinburgh Emergency Medicine in collaboration with RCVS Knowledge, for use in veterinary practices.

References 

1. Elliott, R.A. et al (2021) Economic analysis of the prevalence and clinical and economic burden of medication error in England. BMJ Quality & Safety, 30 (2), pp 96-105. http://dx.doi.org/10.1136/bmjqs-2019-010206
2. CVS Group (2019) Quality Improvement 2019 Report p. 11. [online] Available from: https://www.cvsukltd.co.uk/cvs-group-publishes-latest-quality-improvement-report/ [Accessed 11 May 2022]
3. Wallis, J. et al (2019) Medical errors cause harm in veterinary hospitals. Frontiers in Veterinary Science, 6, no. 12. https://doi.org/10.3389/fvets.2019.00012
4. Wu, A.W. (2000) Medical error: the second victim. The doctor who makes the mistake needs help too. BMJ, 320 (7237), pp. 726-727. https://doi.org/10.1136/bmj.320.7237.726
5. Oxtoby, C. and Mossop, L. (2019) Blame and shame in the veterinary profession: barriers and facilitators to reporting significant events. Veterinary Record, 184 (16), p. 501. https://doi.org/10.1136/vr.105137
6. Pringle, M. (2009) Significant event auditing – now part of general practice. Prescriber, 20 (2), pp. 6–8. https://doi.org/10.1002/PSB.465
7. Mosedale, P. and Blackie, K. (2020) Why do Medication errors occur in veterinary practice?  UK Vet Companion Animal, 26 (7), pp. 1-4.  https://doi.org/10.12968/coan.2021.0033

About the author

Pam Mosedale BVetMed MRCVS

Pam is QI Clinical lead for RCVS Knowledge and Chair of the RCVS Knowledge Quality Improvement Advisory Board. She was Lead Assessor for the RCVS Practice Standards Scheme until very recently. Pam has worked in first opinion practice for most of her career. She is also an SQP assessor for AMTRA and edits the BSAVA Guide to the Use of Veterinary Medicines and organises the BSAVA Dispensing Course.

Pam has been involved in establishing Quality Improvement resources for the veterinary practice team. She is passionate about QI becoming part of the normal working day for veterinary teams and contributing to a just learning culture in practice.