Danny Chambers
Over a decade ago, when I was a recent veterinary graduate, I accidentally cut into the large colon of a young cat during a spay. I repaired the bowel wall. The cat seemed to recover okay, but after about two weeks the cat became very unwell and died. Post-mortem revealed the cause of death was peritonitis - an infection of the abdomen- which was almost certainly as a result of me perforating the colon a couple of weeks earlier.
The Critical Paradox – As scientists, in order to learn from our mistakes, we need to be self-critical. On the other hand, high levels of self-criticism can lead to depression.
In the weeks that followed the incident I felt as though I should never pick up a scalpel again. I felt a huge amount of guilt that an animal had died during an elective procedure. I felt incompetent. I felt shame in front of my colleagues. I felt sad for the 5 year old boy for whom the cat had been a birthday present. The whole point of being a vet is to heal animals, not to harm them.
We all make mistakes. In many walks of life it is possible to admit to our mistakes, correct them and learn vital lessons from them. But for veterinary surgeons, mistakes can be permanent and catastrophic.
Learning from your mistakes and those of your professional colleagues is fundamental to learning and improving.
However due to the structure and culture of the veterinary industry, reporting and documenting these mistakes can often be more problematic than constructive resulting in disapproving bosses, owner complaints or social media abuse, and personal guilt.
The reason commercial flying is an extremely safe activity is because the aviation industry has encouraged a ‘just culture’ for decades. A just culture allows the causes and contributory factors to be identified and understood, and in turn facilitates the implementation of systems, protocols and checklists to ensure that errors are learned from and mitigated against, so the chances of errors are reduced year on year. This not only reduces the chance of individuals making errors, but the organisation as a whole.
Here’s how the NHS defines a ‘just culture’:
'In a just culture, inadvertent human error, freely admitted, is not normally subject to sanction in order to encourage reporting of safety issues.
'In a just culture, investigators principally attempt to understand why failings occurred and how the system led to sub-optimal behaviours.
'However a just culture also holds people appropriately to account where there is evidence of gross negligence or deliberate acts’.
The veterinary profession needs to foster a just culture, or a ‘learning culture’ to encourage the reporting and documentation of errors without fear of the consequences. This allows us to identify the causes of the errors, which in turn seeks to improve and inform the systems, protocols and support that needs to be put in place to reduce the likelihood of these errors occurring again within the practice. It is also important to include a debrief after the event, and to provide emotional support to the individual who made the error.
There are multiple factors at play as to why it has been difficult to foster a learning culture in veterinary medicine, and we will explore some of these.
Lack of Support Systems
It is important to recognise that many veterinary errors are the result of an individual working within inadequate support or mentoring systems.
In human medicine, doctors graduate from university and enter into a formal NHS employment structure. This system involves further training, support and various levels of supervision depending on experience.
Traditionally, newly graduated vets haven’t had the same standardised support and training once they enter into practice. The level and quality of mentorship, supervision and further training very much depended on the practice owners and other staff you happened to work with in your first job.
A common approach to a spay in a cat is the left flank. Rather than attempting to repair the colon through this flank incision, after reflecting on my error and with the benefit of experience, I now realise that I should have closed the initial flank incision and opened the abdomen along the midline to better access and visualise the area when attempting the colon repair. The business model of that practice sometimes resulted in inexperienced vets having to operate with no other vet in the building. This lack of clinical support or advice from a senior vet meant I had no guidance as to how best to fix the error once it was made.
The Royal College of Veterinary Surgeons has recently introduced a compulsory mentorship program to ensure veterinary practices employing new graduates have trained mentors to provide support and guidance This initiative should help reduce the likelihood of avoidable clinical mistakes being made, and also help develop resilience and confidence.
Mental Health
It is no secret that veterinary professionals suffer from mental health issues, anxiety, compassion fatigue and burn out at much higher levels than the general population do.
The perfectionist personality types that seem to be very common among vets means that making a mistake can exacerbate feelings of shame, embarrassment, fear of being struck off, feelings of inadequacy, and feelings of being incompetent.
Perhaps most of all, is the fear that an upset animal owner may take to social media in order to broadcast the mistake, causing stress for the individual vet and practice having to deal with the resulting fall out.
There are many places vets can turn to for help and support if they have made a clinical mistake, from Vetlife to the Veterinary Defence Society. However, a veterinary practice embodying the philosophy of a learning culture will mean the individual who made the error will receive a lot of support and mentorship from within the team, without feeling judged by their colleagues or employers.
Proactive reporting
Humans will inevitably make mistakes but with continually assessed and improved systems in place we can mitigate these.
The NHS has an incident reporting policy that ensures it manages and investigates all incidents in accordance with best practice, learns and shares lessons from them and takes appropriate action to protect those involved from harm. They do this by recording and investigating adverse incidents and auditing the data.
In order to encourage reporting in veterinary practice, we need to foster a learning culture where vets are admired for admitting their mistakes rather than feeling that their reputation is going to be damaged.
New initiatives such as Vetsafe from the Veterinary Defence Society allow mistakes, errors and near-misses to be reported confidentially to help the profession understand better how they occur, reduce the likelihood of them happening again, and to support the ‘second victim’ - that is the clinician who has made the mistake.
What if things had turned out differently?
I was fortunate and very grateful that the owners of the cat were understanding despite being very upset. What if the owners of this cat had not been so reasonable and forgiving? What if they had been determined to see me punished in some way?
They could have lodged complaints to the RCVS in an attempt to put me through a stressful disciplinary hearing. It goes without saying that an accident or mistake will never lead to an RCVS disciplinary hearing - unless it is covered up or repeated multiple times.
The owners could have taken to social media to express their outrage, whipping up anger among other animal owners. This would have been devastating to my personal and professional confidence, especially in the early stages of my career because the truth is, I couldn’t have been made to feel worse than I already did. I may well have joined the high proportion of vets leaving the profession before they are five years graduated.
We need to discuss our mistakes
In an attempt to encourage younger colleagues and students, it’s becoming more commonplace for vets to talk openly about setbacks with regards to their careers. For example, vets often recount times they failed exams, or applied unsuccessfully for jobs or other positions, but got there in the end. However, it is much easier to share career setbacks than it is to admit to making clinical mistakes that resulted in an avoidable death.
That fatal cat spay is something that pops into my mind every time I scrub up for a surgery. Every vet and nurse has a case that haunts them on a regular basis. I have chosen to learn and reflect from this incident, ensuring that I or any students I’m teaching will be very unlikely to repeat this error.
As a result of this error I’ve grown hugely as a person, developed as a vet and I’ve certainly become a better surgeon because of it.
As one surgeon told me, it is a rare but alarming thing to meet a surgeon without fear. “If you’re not a little afraid when you operate, you’re bound to do a patient a grave disservice." - Atul Gawande
It is vital that clinicians adopt a growth mindset, that we demonstrate we can learn from our mistakes, that we can identify the reasons they occurred in the first place, and that publicise and communicate them so others can learn also.
We also need to be realistic and pragmatic. Vets are only human so we need to recognise that no matter what systems and support is in place, mistakes will be made. We must accept that making an error does not preclude someone from being a competent, caring, and diligent vet. We can recognise that neither our over-stretched veterinary profession nor animal welfare in general would benefit from a vet quitting due to a mistake, even if the consequences were severe.
Growing from failure
While it may not have been of any comfort at the time, the owners of that cat can be assured that this mistake has made me a better surgeon, a better teacher, and someone who is passionate to ensure vets are working in supportive environments where these mistakes are less likely to occur.
In his excellent book ‘Complications,’ the writer and surgeon Atul Gawande observed:
Even worse than losing self-confidence, though, is reacting defensively. There are surgeons who will see faults everywhere except in themselves. They have no questions and no fears about their abilities. As a result, they learn nothing from their mistakes and know nothing of their limitations.
Danny Chambers is an elected Council Member of the Royal College of Veterinary Surgeons, a trustee of the mental health charity Vetlife, and a trustee of the evidence-based medicine charity RCVS Knowledge. Further resources:
For those wanting to understand more about just culture and reporting adverse events, there’s a huge amount of support and resources at RCVS Knowledge and Vetled. Danny would like to thank Vetled for their input into this article.