Adverse events / Fatalities

• inFOCUS summary of:
  • Mortality related to general anaesthesia and sedation in dogs under UK primary veterinary care. [inFOCUS][online]. Available from: https://www.infocusvj.org/mortality-related-to-general-anaesthesia-and-sedation-in-dogs-under-uk-primary-veterinary-care/ [accessed 17/11/2022].
• Blackie, K. and Mosedale, P. (2021) Why do medication errors occur in veterinary practice? Companion Animal. 26 (7) (subscription required) https://doi.org/10.12968/coan.2021.0033 [RCVS Knowledge Library members, click here] (CPD: 28 minutes).
• Blackie, K. and Mosedale, P. (2021) Reducing medication errors in practice: part 2. Companion Animal. 27 (1) (subscription required) https://doi.org/10.12968/coan.2021.0061 [RCVS Knowledge Library members, click here] (CPD: 40 minutes).
• Mosedale, P. (2017) Learning from mistakes: the use of significant event audit in veterinary practice. Companion Animal. 22 (3), pp. 140-143 (subscription required) https://doi.org/10.12968/coan.2017.22.3.140 [RCVS Knowledge Library members, click here] (CPD: 15 minutes).
• Turner, M. (2021) Building a safety culture in practice - a whole team approach. (CPD: 16 minutes)
• White, S.C. (2018) Veterinarians’ emotional reactions and coping strategies for adverse events in spay-neuter surgical practice. Anthrozoös, 31 (1), pp. 117-131 (subscription required) http://dx.doi.org/10.1080/08927936.2018.1406205 [RCVS Knowledge Library members, click here](CPD: 68 minutes)
• Fletcher et al (2012) RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: Clinical guidelines. Journal of Veterinary Emergency and Critical Care https://doi.org/10.1111/j.1476-4431.2012.00757.x (CPD: 75 minutes).
• inFOCUS Spotlight topic on:
  • Reducing errors in veterinary practice [inFOCUS][online]. Available from: https://www.infocusvj.org/revp-reducing-errors-in-veterinary-practice/ [accessed 20/4/2022].

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Use these tools to help you process an adverse event when it happens. By encouraging a just culture you can get to the true cause of an event, support your team and improve patient care.

• QI Boxset Series 6: Learning from everything - significant event audits and root cause analysis: This course will show you how to perform a significant event audit, find out the root cause of an event, and help encourage a just culture. This course is broken up into bite-sized episodes, making the content easy to access. (CPD: 4 hours for total completion of all episodes).
• Significant Event Audit Walkthrough: A handy infographic that explains the process of a significant event audit. Ideal to print! [PDF 159KB] (Updated June 2023).
• Significant Event Audit Report Template: You can use this template to structure your significant event audit [Word 41KB] (Updated June 2023).
• Root cause analysis in action (CPD:10 minutes): This document discusses root cause analysis, the 5 whys, contributory factors checklists and the cause and effect diagram. 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 away from a blame culture [PDF 2114KB] (Published January 2020).
• Contributory factors checklist: You can use this checklist to assist in significant event audit meetings, and to help identify the root cause of an event [Word 41KB] (Published February 2019).
• Cause and effect (fishbone) template: When undertaking a significant event audit, this diagram can help your team find the possible root cause(s) of a problem [Word 104KB] (Updated June 2020).
• Hot debrief data collection form: STOP5 or ‘Stop for 5 Minutes’ is a hot debrief framework that can be led by any member of the resuscitation team. The purpose of this confidential, blame-free, team debrief is to improve patient care and to deliver timely support to team members after difficult or distressing clinical cases [PDF 348KB] (Updated May 2021). Find out more in our new QI feature, When it all goes wrong: the importance of debrief. 

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These case examples show how practices have performed significant event audits in practice, and the changes they instigated to improve their patient care.

• A rabbit anaesthetic death (CPD: 20 minutes): After a team lost a rabbit patient under anaesthetic, they perform a significant event audit to find out what happened and see if processes can be changed to help prevent it from reoccurring [PDF 511KB] (Published November 2019).
• Fentanyl CRI overdose (CPD: 10 minutes): This case example details a significant event audit that was completed in practice after a patient received an opioid overdose. It is useful to see the steps undertaken to complete the audit, and what information was discovered that led to the cause of the event [PDF 180KB] (Published March 2019).
• QI Vets: Drug calculation error (CPD: 10 minutes): After returning from furlough, the team are overwhelmed and a patient receives the wrong dose of a pre-medication.This case example shows how the team analysed what had happened and the process they put in place to reduce the risk of other team members making the same error [PDF 18yKB] (Published February 2021).
• QI Vets: Meloxicam overdose (CPD: 18 minutes): A patient is admitted after being given a 45kg dose of meloxicam instead of a 4.5kg dose. This case example shows the processes the team took to identify how this happened, and how to change to improve patient safety [PDF 519KB] (Published September 2020).
• CPR on a patient (CPD: 10 minutes): This case example details a significant event audit that was completed in practice after a patient deteriorated and cardiopulmonary resuscitation was required. It is useful to see the steps the team took to provide care to the patient and each other, as well as the processes that were in place to help [PDF 499KB] (Published June 2019).

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