Abandoning the Blame War: Responding Effectively to Medical Malpractice

Medical errors can mean the difference between life and death, but they are also a reality of veterinary medicine. When humans are involved in the process, mistakes are bound to happen, says Lauren Forsyth, Ph.D., clinical assistant professor of pharmacy and director of pharmacy services at the University of Illinois Veterinary Teaching Hospital.

She presented the session “Error Prevention: How to Do Your Part” at the 2023 Student AVMA (SAVMA) Symposium on March 17, addressing processing systems within veterinary medicine to prevent harmful errors. .

She referred to an article from March 2018 Java The study reported that of the 606 veterinarians who responded to the survey, 73.8% were involved in at least one near miss or adverse event.

“We need to change the question from ‘who’s to blame?’ to ‘what’s to blame?'” said Dr. Forsythe.

According to a 2015 Vet Record survey of the types of mistakes in veterinary practice, surgical errors were the most common medical errors. A review of 74,485 veterinary cases found that nearly 40% of adverse events may be related to surgery. Of these cases, the majority were from general and orthopedic surgery.

Another study examining veterinary hospital processes found that 54% of medical errors were drug-related, followed by miscommunication. Drug-related events were primarily caused by deficiencies in the dosing process, such as administering the wrong dose or treating the wrong patient.

Medication errors occur when labels are unclear, devices are poorly designed, drugs are stored improperly, and error-prone abbreviations are used, Dr. Forsythe said. There is a tendency to

Prevention of medical errors

Medical malpractice reporting for data analysis in veterinary medicine is not mandatory, but some institutions have their own systems. For example, in 2015, Cornell University introduced a voluntary online incident reporting system for the small animal and large animal departments of its veterinary hospital.

Dr. Forsythe explained that the University of Illinois School of Veterinary Medicine created an incident reporting system modeled after Cornell University to understand the occurrence of medical errors and near misses. She said how medical professionals deal with these issues internally impacts the entire team.

“If we don’t talk about medical errors, we’re going to make the same mistakes over and over again,” she said.

Dr. Forsythe guided session participants through the six steps for responding to medical malpractice, extracted from a July 2018 article on the Veterinary Idealist blog. Here are the steps:

  1. Patients should always come first.
    As soon as an error is observed, the ongoing damage should be minimized.
  2. Notify your client immediately.
    The client specifically wants confirmation that an error has occurred. They want to know what the error was, why it happened, and they want a sincere apology.
  3. Support involved healthcare workers.
    People who make mistakes are often referred to as “second victims” because they end up experiencing visible suffering as a result of their mistakes. It’s important to ask them if they’re okay and help them establish healing as they move forward.
  4. investigation
    It’s important to understand why the mistake happened. This is necessary to share with clients and make appropriate changes to the system. The purpose of the investigation is not to identify or impose responsibility. Instead, the key question to ask is, “Could it be possible that another person in the same situation made the same mistake?”
  5. Round back to the client.
    Clients need closures that include information such as clinical impact, long-term prognosis, findings, and future prevention plans.
  6. We will work on fixing the system in-house.
    Creating a process to report, track, and investigate all medical errors, including near misses that did no harm, provides valuable data for improvement.

“Adverse events should be used as learning opportunities,” says Dr. Forsyth.

do better next time

Dr. Forsythe said the old idea of ​​re-education, relying on people to remember more information, is not effective. Hard work alone won’t get the solution, but changing the system of care will.

The need to focus on mitigating risk makes it less reliant on memory and tasks are redundant and difficult to do wrong in the first place. This may look like error prevention, such as using barcodes for medication.

“In the medical field, we’re taking a lot of steps to make sure people are well educated before they’re placed in a decision-making position,” Dr. Forsyth said.

Leaders must be committed to providing quality, quality care and holding everyone, including themselves, accountable for quality improvement efforts.

“Punishments only reduce reporting and are counterproductive in addressing these errors,” Dr. Forsythe said. “Culture can have a greater impact on outcomes than equipment, technology and facilities.”

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