Error, Mishaps and Learning from Everything

When working in complex sociotechnical systems such as veterinary practice it is accepted that error can and does occur. However, it is how we respond to error and adverse events that is most important. As Liam Donaldson states, ‘to cover up is unforgivable and to fail to learn is inexcusable’. Therefore, it is important to consider what systems can be put in place to ensure that those involved are supported and how the whole team can learn from events to avoid them happening again.

Within the veterinary profession it is easy for learning to become synonymous with continued professional development: leaving the practice to learn something new, a new clinical technique or ways to expand and improve our clinical knowledge. However, it is just as important to learn from everyday work as done, carefully considering the challenges we face, what went well, what could have gone better and what we could do differently next time.

Historically the starting point of safety concerns has been the occurrence of accidents or adverse outcomes and to seek to remove or eliminate them to ensure that as few things as possible go wrong. This is known as a Safety I approach. Using Safety I we manage safety by reacting or responding when something happens, investigate the incident to identify a cause and see humans as a hazard or liability. The purpose of accident investigation in Safety I is to identify causes and contributory factors of the adverse outcome through critical incident reporting or learning discussions and eliminate causes or improve barriers to future occurrence.

However, this is only a small part of the picture. As illustrated by Erik Hollnagel in his white paper From Safety I to Safety II, if the statistical probability of a failure is 1 out of 10,000, we can expect things to go right 9999 times out of 10,000 [1]. While we do not know the failure rate in veterinary healthcare it is safe to assume that things go right much more frequently than they go wrong. Therefore, if we only focus on the things that go wrong, we are missing a huge opportunity to learn. According to Hollnagel, the probability of excellence occurring is similar to that of error. By understanding this approach, it is possible to move to a Safety II approach, where teams are proactively and continuously trying to anticipate developments and events, humans are seen as resources and safety is defined as ‘as many things as possible going right’.

Whether you are listening to football managers, business directors or healthcare professionals the same theme frequently emerges: to improve, we must first observe, listen and seek to understand. By doing this we can learn and then we can consider change. When we truly understand and learn from our work, we can create aims that ensure continuous improvement of the quality of veterinary care. For example, to reduce the cardiac arrest rate by 50% across NHS Lothian, an extensive and comprehensive review of cardiac arrests and medical emergency calls was carried out. Data were gathered from everywhere (not just adverse incidents) to achieve a greater understanding of what both failure and success looked like. By learning from all aspects of the spectrum it was possible to design interventions which enabled cardiac arrests to be greatly reduced.

Currently in veterinary practice, we recognise the importance of learning through talking. By talking about adverse events, we can prevent others making the same error and therefore improve patient care, for example in clinical meetings or using specific morbidity and mortality rounds. By discussing what went wrong and what went right in a case with compassionate colleagues in a safe space we can shed some of the upsetting feelings we encounter.

Research tells us that there is increased evidence of mental strain and suicide risk in the veterinary profession and the UK charity VetLife reported a 25% increase in calls between 2019 and 2020; therefore, it is vital that we put steps in place to support veterinary teams and individuals when things go wrong.

We know that team members feel emotionally traumatised when adverse events occur and experience a multitude of symptoms that can last for months to years; this is known as ‘second victim’. It can cause damage to the physical and emotional health of the affected person, and deteriorating individual and team performance can ultimately compromise patient safety. It is therefore of paramount importance that we ensure that second victims learn from the experience and feel that something good has come from it.

A hot debrief is the first step in this process and can be used to ensure that support is delivered to team members after challenging or upsetting clinical cases. It can be led by any member of the team and is confidential and blame-free. The debrief begins with asking if everyone is ok? At this stage it is important to ensure that thoughts and feelings are listened to and acknowledged, and immediate needs are identified. Then the case is summarised: what went well, where could we improve and what are the actions and responsibilities that should be allocated and completed now?

Learning discussions or morbidity and mortality rounds support a systematic approach to the review of patient deaths or care complications to improve patient care and provide professional learning.

Morbidity and mortality rounds provide an open, nonjudgemental, confidential, and collaborative setting for the review of adverse events. Through identification and presentation of a case where an adverse event has occurred, multidisciplinary reflective discussion, analysis, and identification of contributory factors morbidity and mortality rounds provide a powerful tool to educate staff and improve patient safety and care.

It is important to understand that learning from error and learning from excellence should not be positioned as an either/ or. By highlighting the importance of both and how they work in synergy to ensure that we learn from everything and appreciate the whole picture, we ensure high performance in teams and through high performance we can make sure that patient safety is at its peak.

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