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Mistakes: Why Do They Happen?

Updated: Jun 26, 2023

Robyn J Lowe & Danny Chambers

People working within Veterinary Medicine are among the most diligent of any industry, mistakes occur not because of negligent people but the system within which they work, which can be made safer.

Mistakes happen because of ‘human factors’ and ‘system factors’, when an individual makes a mistake it is likely as a result of a multitude of contributing factors that influenced the end negative outcome.

Kohn et al (2000) noted:

‘single events or errors are due most often to the convergence of multiple contributing factors. Blaming an individual does not change these factors and the same error is likely to recur.’

Human Factors

If the design of equipment, technology and systems do not accommodate the way people work it makes work more stressful and more prone to errors. The science of human factors or ergonomics studies the interactions of humans and other elements of a system in order to optimize well being and overall system performance.

Investigations into human factors are used to understand where and why systems, protocols, standard operating procedures or processes break down. Human factors also include cognitive limitations, individual factors such as stress or tiredness and more rarely in veterinary medicine lack of technical skill and inadequate care. When looking at an error, using the human factors approach aims to consider the causes, circumstances, conditions and other factors connected with the event. Studying human factors can result in the creation of safer systems and the reduction of working conditions or inadequate systems that lead to errors being made.

System Failures

Leape et al (1994) state:

‘Accidents are more likely to happen in certain types of systems. When they do occur, they represent failures in the way systems are designed. The primary objective of systems design ought to be to make it difficult for accidents and errors to occur and to minimise damage if they do occur’

System failures include communication breakdown, leadership, poor design in product or equipment provided, productivity and owners influence. With every mistake the human behind it is likely to have experienced a number of factors leading up to the event- so emphasis should be to change the system not reprimanding the person.

Serious Event Effects: Who’s the victim?

Commonly when a mistake happens in veterinary medicine it will influence other individuals or multiple individuals e.g the patient, the client, the practice. Whilst these individuals clearly need support in the appropriate way it is important to also be aware of the ‘second/third victim’.

Veterinary Professionals hold themselves to extremely high standards, putting immense and sometimes unobtainable pressures and standards on themselves in their daily performance. This inevitably means that when a mistake is made they are traumatised from the event and this can cause serious mental health issues.

Kogan et al (2018) stated:

‘... findings suggested that many veterinarians experience emotional distress after a medical error. Support should be provided to mitigate this adverse impact on the well being of veterinarians and, potentially, their future patients.’

Scott (2009) detailed the events that happen after an adverse event: Chaos and accident response, intrusive reflections, restoring personal integrity, enduring the inquisition, obtaining emotional first aid and finally moving on.

Scott (2009) stated:

‘Despite a growing literature base that shows unexpected clinical events can have ominous emotional consequences, most second victims don’t get adequate support from employers. Instead, they suffer tremendous anxiety and stress alone and in silence. Without appropriate support, they may experience long-term sequelae and pro-longed personal suffering. Some decide to leave their profession.’

The veterinary profession is already experiencing mental health issues and retention issues. The fear of retribution, public humiliation by owners, the opinion of colleagues and disappointment of bosses as well as their own impossibly high standards already puts immense pressure on these individuals. The psychological effects that follow from a mistake can be crippling and lead to loss of perfectly competent and compassionate individuals from the profession, a loss the profession cannot afford. We need a culture of support that encourages reporting of adverse events, followed by system changes that aims to support a team to avoid similar issues occurring again.

Further Reading:

Robyn Lowe FdSc, Dip AVN (Small Animal), Dip HE CVN is a small animal Registered Veterinary Nurse (RVN) who regularly writes articles for academic journals and publications for animal owners. Robyn has a passion for evidence-based medicine, volunteers for Canine Arthritis Management, runs the Veterinary Voices Public Page, and campaigns on mental health and animal welfare issues.

Danny Chambers BVSc MSc MRCVS is a vet and a council member of the Royal College of Veterinary Surgeons. He is the founder of Veterinary Voices UK, has campaigned on mental health and animal welfare issues in the national media, is a trustee of the evidence-based medicine charity RCVS knowledge, and has worked on public health and veterinary projects in India, Iraq and The Gambia.



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