In the veterinary field, how are medical errors viewed, and how ought they to be viewed? Melinda Larson, DVM, DACVIM, director of medical quality at BluePearl Pet Hospitals in Clearwater, Florida, and Richard Stone, DVM, DACVIM, chief medical officer at BluePearl Pet Hospitals in Houston, Texas, gave a lecture at the 2024 American College of Veterinary Internal Medicine (ACVIM) Forum in Minneapolis, Minnesota. They discussed the significance of establishing a culture and system within the health care profession that not only encourages open discussion of medical errors but also views these errors as teaching opportunities.1.
Thinking beyond the box and de-stigmatizing errors
Journalist, author, and broadcaster Matthew Syed’s “black box thinking” methodology—which is exemplified in Syed’s book of the same name—was at the center of Larson and Stone’s talk. The aviation industry keeps all voice and flight data records from the cockpit, which were formerly kept in a black box, as Larson and Stone stated. These boxes are intended to identify the exact location of an incident’s failure, and the information gathered is utilized to create plans of action to stop reoccurring incidents in the future.
Larson continued by emphasizing that the black box approach used in aviation could be used in the medical field. “Black box thinking is defined as developing processes and cultures that let organizations learn from their mistakes instead of feeling intimidated by them. The science of patient safety is truly this learning mindset, this learning mentality, which is the fundamental basis, the speaker said.
Talking about words and phrases that might “trigger people to put up their defenses,” Stone described how terms like “medical error,” “adverse event,” “near miss,” “harm” or “committed,” and “error” can make people avoid talking about specific incidents. The presenters urged medical personnel to use the more inclusive word “patient safety event,” which does not have the same negative connotation as other related language, to help lessen some of this stigma.
During their meeting, Larson and Stone talked about how often errors are in the medical field. A 2016 study found that the third most common cause of death in the US was patient safety incidents involving medical personnel.2. Furthermore, an adverse event damages roughly 1 in 10 patients, and more than half of those damages are thought to be avoidable.1. Despite the paucity of research on the subject, a study conducted on 606 veterinarians revealed that nearly 74% of them had experienced at least one near-miss or adverse event and over 50% had been impacted by these incidents on both a personal and professional level.1,3
The field of health care is incredibly complex, encompassing both human and veterinary medicine, which makes it prone to errors. However, health professionals stigmatize human fallibility and possess little to no expertise in error identification or management, according to Larson.
Systems-thinking
Larson and Stone expounded on the value of incident reporting systems, which give team members a mechanism to document any patient safety occurrences that take place at work, as part of the “black box thinking” methodology. Similar to aircraft black boxes, this data collection on each incident aids businesses in identifying patterns in these incidents, hence presenting opportunities.
According to Larson and Stone, contrary to popular opinion, most patient safety occurrences are rarely the exclusive responsibility of a single person. Errors, on the other hand, are complex phenomena that arise from complex systems with many interrelated causes. According to Larson, “People exist within systems; medical errors are rarely as simple as a single person doing something wrong.” Therefore, Larson and Stone recommended developing “systems thinking,” as this way of thinking serves as the basis for understanding and enhancing patient safety incidents.
After implementing systems thinking, “root cause analysis” can be used. This phrase describes the systematic and thorough analysis of medical errors to identify the mistake and modify the system to make it less likely to happen again.
References
- Discovering the black box: Acquiring knowledge from medical mishaps Larson M, Stone R. Presented on June 5–8, 2024, Minneapolis, MN: American College of Veterinary Internal Medicine Forum.
- Wu AW, Low R. For the sake of both patients and medical teams, there should be more discussion regarding errors in veterinary healthcare. 2022;36(6):2199–2202; Journal of Veterinary Internal Medicine. 10.1111/jvim.16554 can be found here.
- Schoenfeld-Tacher RM, Hellyer PW, Rishniw M, Kogan LR. The experiences of veterinarians with unfavorable incidents and near misses. In 2018 J Am Vet Med Assoc., 252(5): 586–595. The doi: 10.2460/javma.252.5.586 is available.
