When veterinary surgeons treat patients, the biggest source of mistakes is human error, according to a new study.
The majority of errors were caused by the limitations of memory and attention leading to slips, lapses, and mistakes that can occur when distracted or under stress.
The research, led by researchers in the University of Nottingham’s School of Veterinary Medicine and Science and School of Psychology, supports the need for the development and implementation of interventions similar to the ones that protect patients in human medicine, such as the World Health Organization’s safe surgery checklist.
“I hope this paper will shine some light on a difficult and sensitive subject in the profession,” says lead researcher Catherine Oxtoby. “The vast majority of veterinary surgeons and nurses are dedicated, compassionate people who care deeply about both their patients and their clients, but they are also human beings and occasionally make harmful mistakes.
“We have to understand that mistakes don’t happen because someone was being careless—it’s much more complicated than that, and blaming the clinician does nothing to prevent it happening again.
“What we need are simple tools to support clinicians and help reduce mistakes. This is an area of active policy and research in medicine but is relatively untouched and poorly understood in our profession.”
Over the last 25 years, the medical profession has investigated the main causes and types of medical error to develop an evidence-based understanding of the factors that lead to mistakes and the types of the most common errors, followed by the development of interventions to reduce risks.
Vets also make mistakes but the profession has no tools to classify veterinary error and a limited understanding of the causes of mistakes and the associated contributing factors. This research starts the move towards such a system.
The research identifies causes or error from analysis of 678 claims to the profession’s leading indemnity insurer. Nine focus groups with vets, nurses, and support staff took place and participants asked to anonymously recall some personal examples of errors they had made or witnessed.
Types of errors were taken from 2,978 claim records reported between 2009 and 2014. Mistakes involving surgery was the most common type of error while human error (cognitive limitation) topped the table of causes of error. Other causes included failures of communication and clinical leadership, design of products, and equipment and pressures such as staffing and covering out of hours care.
Significantly, inadequate care or negligence was found in less than one percent of all the claims made.
“I would like to thank all the vets and nurses who participated in the research,” says Oxtoby. “I was often touched by how much they cared.
“I hope that this research has the potential to lead to changes in attitudes, increased trust, and confidence between vets and their clients and ultimately more resilient systems to ensure consistent quality of care, through a better understanding of the true causes of veterinary medical error.”
The findings appear in The Veterinary Record.
Source: University of Nottingham