Pam Mosedale
The implementation of a ‘just’ culture in responding to veterinary adverse events allows for a more reflective approach, likely to result in learning and improvement. Taking responsibility for one’s actions is important, but experiencing emotional turmoil and a profound negative impact on mental health is not a desired outcome.
A system for team members to respond to error, which promotes fairness, justice and learning, will benefit patient safety as well as reduce fear of retribution. It will put steps in place to encourage a culture of learning and improvement. This system should include a way to record errors or near misses, as well as an approach to responding to these incidents and to decreasing the risk of them happening again.
The Veterinary Defence Society have an adverse event reporting system, ‘Vet Safe’, available to their members. RCVS Knowledge has free resources available for teams to embed an approach to responding to errors and near misses (a Significant Event Audit course, template, walkthrough, contributory factors analysis tools, and many real case examples).
How to: Significant Event Audits
Michael Pringle, formerly Professor of General Practice at University of Nottingham, defines a significant event as:
“ an event thought by anyone in the team to be significant in the care of patients or the conduct of the practice” (Pringle et al, 1995).
A Significant Event Audit (SEA) is:
“A process whereby significant occurrences (not necessarily [only] involving an undesirable outcome for the patient) in individual cases are analysed in a systematic and detailed way to ascertain what can be learnt about the overall quality of care given and to indicate changes that might lead to future improvements”. (Rooke et al, 2022).
By introducing the formal approaches of a Significant Event Audit, the team can avoid blame culture, and can instead turn an adverse event into an opportunity to learn and to introduce improvements for the whole practice team, their patients and owners.
How practices can make a start with Significant Event Auditing
Step one: keep a log
Practices should keep a log of significant events. These do not all need to be clinical, however. They can be anything that is significant in the care of the patients or the running of the practice. They can include serious errors, like incorrect medication given to a patient, or moderate errors, such as when lab results go astray. Non-clinical events that impact on the practice can also be discussed, as can occasions when everything goes right. A Significant Event Audit can be used to celebrate and learn from successes, as well as mistakes.
Near misses are also a valuable area to include in a log of events, to reduce the likelihood of them recurring and progressing to an error the next time.
Involving the team who actually do the work is vital – they are best placed to have an understanding of the causes of incidents, and the most practical and pragmatic potential solutions.
Step two: involving the whole team
Gather information such as clinical records, consent forms, guidelines, protocols, checklists, complaint letters, feedback from clients, etc, alongside accounts of the event from all the individuals involved.
Sometimes events which seem on the face of it purely clinical (for example, a rabbit anaesthesia death) may have started in the waiting room (owner waited for a long period with rabbit in box next to barking dog). Getting the view of the client care team is therefore also important.
Involving the whole practice team in discussing these incidents is vital to get a holistic view on the situation.
Step three: the meeting
The meeting to discuss the significant event should be non–threatening, open, and fair. It needs to be clear to the team that the meeting is to encourage reflection and learning, and to provide an opportunity to look at practice systems and procedures rather than to blame individuals. Someone to chair the meeting, can be very useful to keep everyone on track and maintain ground rules. The positive discussions and changes in systems, without blaming individuals after a negative event, can improve teamwork, communication and team morale (Bowie & Pringle, 2008). It can also contribute to improving practice culture.
Step four: Finding the root cause or contributing factors
Finding root causes, taking the time to fully understand what contributed to the event rather than jumping to conclusions, is a really important part of looking at significant events. This can be done in many ways, including using the ‘five Whys’ technique: not taking the first explanation, and asking why at least five times to get to the base of the issue. This can work for simple problems but is not suitable for more complex situations and can be open to individual interpretation ( The problem with 5 whys BMJ Quality & Safety A J Card, 2016) 26 pp 671-677). A Fishbone Diagram, also known as a cause-and-effect diagram or Ishikawa diagram, can be used to look more fully into all the factors involved.
A more structured method of looking for root causes is a contributory factors checklist. This is particularly useful when an event is likely to have multiple causes.
Whichever method of root cause analysis is used, it is important that the whole practice team know what is happening and that the analysis is being used to improve systems, not blame individuals, and that the analysis leads to action with the aim of improving the areas identified.
Step Five: Making changes
The meeting should result in recommendations for change. These may include whole team training and drawing up or modifying guidelines, protocols or checklists. Any changes, once implemented, should be followed up to see whether they have had the desired effect or if they are being used as they should be.
Significant Event Audits will engage the whole practice team with Quality Improvement and evidence-based veterinary medicine, to learn from strengths and weaknesses and improve patient care, outcomes, and learning, and will improve morale for the whole team.
It is important to review the changes made to ensure they have been effective. The team should consider whether the changes should be adopted generally, adapted to the circumstances of the practice, or even abandoned if that is what is best. Perhaps the change resulted in unintended consequences, and a different improvement effort should be put in place instead.
Practice culture
Changing practice culture can seem like a daunting task, but practices, management, and teams’ attitude to errors is an enormous part of the culture we experience.
In practices with a psychologically safe culture, team members feel comfortable admitting their mistakes or speaking up when they see that something is not quite right. This will facilitate serious incidents being avoided, lessons being learned, and ideas shared.
In a just culture, team members are accountable for their actions and reckless behaviour is not tolerated, but systems are in place to avert undue blame.
Practices that engage with Quality Improvement activities – look at the evidence base, using it to draw up guidelines or checklists, measure what they do with Clinical Audit – are proactive in making changes to lead to improvements. They listen to their team members, use errors as opportunities to learn rather than to blame individuals. Such practices are taking steps along the road to improve practice culture.
Further reading:
The Importance of Debrief: www.rcvsknowledge.org/news-and-events/features/when-it-all-goes-wrong-the-importance-of-debrief/
How Leaders can Enhance Safety Culture: www.rcvsknowledge.org/news-and-events/features/how-can-leaders-enhance-safety-culture-the-importance-of/
Why Just Culture Matters for Safer Systems: www.rcvsknowledge.org/news-and-events/features/why-just-culture-matters-a-safer-system-for-quality-improvement/
Pam Mosedale BVetMed FRCVS is QI Clinical Lead at RCVS Knowledge and Chair of the RCVS Knowledge Quality Improvement Advisory Board . She was formerly Lead Assessor for the RCVS Practice Standards Scheme. She has worked in first opinion practice for most of her career. 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.