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The Critical Paradox: Changing How We Report Adverse Events

Updated: Apr 27

Robyn J Lowe & Danny Chambers

The critical paradox highlights the need for scientists to learn from their mistakes, the ability to be self critical of outcomes allows a growth and educational mindset. However in the veterinary profession mistakes can be catastrophic. This can lead to high levels of perfectionism and self-criticism that subsequently can lead to depression and anxiety.

Blame Culture

‘Blame Culture’ refers to the response of professionals, organisations and clients in the aftermath of a mistake. Blame culture is damaging not only to the mental health of the profession but also reduces the instance of reporting errors which in turn reduces discussion and learning from those errors. Veterinary professionals need the ability to report adverse events or near misses in a ‘no blame or just culture’ where they learn, grow and most importantly change protocol to avoid similar mistakes happening again to improve patient safety or outcome.

In industries like the Aviation industry the reporting and learning from serious adverse events has led to them being one of the safest in the world. A key basis of this safety culture is the reporting of adverse events in a timely and constructive manner and the organisational response to mistakes that are made in a constructive and supportive way. The Flight Safety Foundation states:

‘One key to the successful implementation of safety regulation is to attain a “just culture” reporting environment within aviation organisations, regulators and investigation authorities. This effective reporting culture depends on how those organisations handle blame and punishment.’

Furthermore Professor Sir Normal William's details what is considered a ‘just culture’:

‘A just culture considers wider systemic issues where things go wrong, enabling professionals and those operating the system to learn without fear of retribution’

In a medical setting the NHS state:

‘The fair treatment of staff supports a culture of fairness, openness and learning in the NHS by making staff feel confident to speak up when things go wrong, rather than fearing blame.’

Humans are not infallible, and will make mistakes, these mistakes are rarely through carelessness or lack of personal skill, but due to a number of human and system errors that are a prelude to the end result. This is an essential consideration when taking into account the culture in which adverse events are dealt with in a veterinary setting.

Creating a just learning culture within the profession

Professionals may feel unable to share mistakes because of the opinion or reaction of their colleagues, bosses, peers or clients. For this reason when discussing mistakes or adverse events it is imperative to consider a few phenomena that might make an individual reassess their response to an adverse event.

Hindsight bias can lead to general overconfidence in the certainty of one’s judgments. The idea that you would have excelled in the task that your colleague somehow ‘failed’, that you would have done things differently, or that you would have noticed that problem before it became an issue.

Cognitive bias is also something that needs to be taken into consideration as it is now becoming more apparent that significant diagnostic error can result from cognitive bias when it occurs in a medical setting. A cognitive bias as detailed by Haselton et al (2005) is a systematic pattern of deviation from the norm or rationality in judgement.

Sullivan and Schofield (2018) state:

‘It is likely that most, if not all, clinical decision-makers are at risk of error due to bias – it seems to be a ubiquitous phenomenon and does not correlate with intelligence nor any other measure of cognitive ability.’

Outcome bias in medicine occurs when the assessment of the quality of a clinical decision is affected by knowledge of the end outcome of that decision. Studies showed that outcomes of a clinical decision whether positive or negative will influence the opinions on the decision with negative outcomes being judged more harshly than positive.

Barriers to veterinary adverse event reporting

In Human medicine, prior to the widespread implementation of a ‘ just and learning’ culture to reporting mistakes, medics cited a number of reasons as to why they are fearful of incident reporting. These include fear of professional repercussions, legal liability, blame, lack of confidentiality, negative patient/family reactions, humiliation, perfectionism, guilt, lack of anonymity and the absence of a supportive forum for disclosure. Many of these reasons are so applicable to veterinary medicine. The community reported being concerned for action against them via RCVS reporting, client reaction and facing public humiliation online, reaction of colleagues or bosses as well as self punishment in the form of high levels of perfectionism, self-criticism. It should be noted that cases of genuine mistakes rarely make it to disciplinary.

Near misses or ‘ Never events’

Near misses are equally as important to report on as the big ‘never events’. The term ‘never event’ describes an incident or error that should not occur if proper safety procedures are followed. However this term should be considered carefully when used in reporting of incidents, as veterinary professionals sometimes do deviate from set protocols if they feel it is justified using their clinical experience and knowledge: medicine isn't always straightforward in presentation. These events are easy to recognize and are usually the focus of reports, however ‘near misses’ should hold equal importance in discussions. These are events that nearly occurred, but did not. WHO defines a near miss as an error that has the potential to cause an adverse event (patient harm) but fails to do so because of chance or because it is intercepted. It has been suggested that the root causes of near misses and adverse events are similar, therefore discussing the root causes of near misses in practice can help the team to correct these, change protocols and SOPs and prevent future adverse events from happening.

Root Cause Analysis

The LONDON protocol provides interesting insight to root cause analysis: why did this event happen? The term ‘root cause’ can be considered misleading as it may insinuate that there is a sole cause for an event. However, when events occur there is usually a chain of events and a wider variety of contributory factors leading up to the incident. The entire practice (including reception, auxiliary staff, veterinary nurses and veterinary surgeons) need to identify which of these contributory factors have the greatest impact on the incident and, more importantly still, which factors have the greatest potential for causing future incidents to occur. By doing this we shift from blaming a single individual, to understanding the wider context of the event and changing the system and protocols in place that will support staff and prevent the possibility of incidence of the event occurring again.

Further Reading:

Robyn J Lowe BSc Hons, Dip AVN (Surgery, Medicine, Anaesthesia), Dip HE CVN, RVN 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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