Incidence of medical errors (ie, acts of omission or commission in planning or execution that can contribute to unintended results) is a focus of concern in human medicine. Research increased following a report from the Institute of Medicine that introduced the importance of patient safety and medical error reporting.1 One study found >250,000 deaths in US hospitals each year could be attributed to medical errors, making this the third leading cause of death in humans.1,2
Medical errors have not been extensively described in veterinary medicine.3,4 One study examined medical error reports (n = 651) from a small animal teaching hospital, a large animal teaching hospital, and a small animal multispecialty practice.4 Drug errors were the most frequently reported incidents (54%) and were frequently categorized as wrong dose administered, communication error, or both. Nearly half (45%) of all errors affected patients but did not cause harm; 15% resulted in harm. Seven patients experienced permanent harm or death. Increased medical error awareness, education, reporting, and resources are therefore warranted in veterinary medicine.4-6
How do medical errors occur?
Consideration of common causes can help effectively address medical errors. The Swiss cheese model depicts opportunities for errors throughout an organization and includes institutional (lack of support), technical (suboptimal or malfunctioning equipment), team (lack of supervision or training), individual (limited knowledge or distraction), and patient (complex disease or communication problems) factors.7 Errors occur when events (ie, holes in the cheese) at each level of an organization align. Causes of medical errors include cognitive errors due to unconscious bias, constrained thinking due to stress, cognitive bias (eg, pattern recognition, unconscious reflexive decision-making more common with increased clinical experience), confirmation bias, lapses in verbal and nonverbal communication, miscommunication, sleeping <6 hours per night, working >70 hours per week, and acute or chronic depression.5,8
What is the best way to respond to a medical error?
When a medical error occurs, the first step should be clinical intervention to prevent or reduce patient harm. Once necessary medical action has been taken, colleagues concurrently working in the clinic and clinic administrators or practice owners should be notified. Important details of the incident (including timeline, witnesses, and patient factors) should be quickly noted to aid with subsequent documentation and analysis. Communicating the error to the client is often difficult but is an ethical obligation and professional responsibility. Reviewing and mentally rehearsing this conversation can help achieve honest, 2-way communication, develop a plan, and maintain trust. Using an acronym model to guide preparation can be helpful (see SPIKES Acronym for Breaking Bad News).8
SPIKES Acronym for Breaking Bad News12
Setting: Arrange a private setting to avoid interruptions, and allow appropriate time for the conversation. Involve significant others, sit instead of stand, and use eye contact to make a connection and build rapport with the client.
Perception: Assess the client’s understanding of the patient’s condition and/or seriousness of the event.
Invitation: Ask the client whether they would like to proceed and, if so, how much they wish to know about the condition and/or treatment. Understand clients have a right to information about the situation, and answer any questions.
Knowledge: Use appropriate language (avoid medical jargon) to incrementally share information, and continually check in with the client to gauge understanding and address reactions. Share positive information first, and provide facts accurately.
Explore emotions and sympathize: Identify, acknowledge, and validate the client’s emotions, as well as the cause of emotions. Respond to the emotions in a way that demonstrates the correlation between the emotion and cause. This might sound like I understand/It sounds like you are feeling angry because Dolly’s test results were misinterpreted, which led to delays in her treatment.
Strategy and summary: Ask the client whether they would like to discuss treatment options (if applicable) or need clarification. Close the discussion with a plan of action.
The patient is the primary victim of a medical error; however, secondary victims (ie, individuals involved in the event who are traumatized or negatively impacted) should also be considered.9 Veterinary team members often have immense empathy and compassion for their patients and clients. Addressing the emotional impact of medical errors and providing support (eg, kindness and understanding from peers, opportunities for self-care [eg, self-forgiveness, shame avoidance]) is therefore important and may help increase error reporting, reduce negative professional and clinical impacts, and prevent subsequent errors due to known causes (eg, distraction, stress, depression).3
How can the risk for medical errors be reduced?
Although preventing all medical errors may not be possible, strategies to reduce incidence and severity should be implemented. A safety culture that encourages medical error reporting without shame or blame and provides support when errors occur is essential. Accreditation standards for human health care organizations require structures and processes that focus on safety and quality, including support for a safety culture and systems for medical error reporting.10 This model has been adapted and encouraged in both veterinary medicine and curricula.6 Instruction on clinical reasoning skills that includes strategies to avoid common causes of medical errors may help improve clinical decision-making (see REFLECT Acronym for Improved Clinical Decision-Making).
REFLECT Acronym for Improved Clinical Decision-Makinga
Recognize assumptions: Consider and question assumptions about the patient and etiology.
Explore alternatives: Investigate alternative etiologies and diagnoses.
Fight bias: Intentionally resist common biases, including availability and confirmation bias.
Look for patterns: View data both individually and collectively.
Evaluate pros and cons: Weigh pros and cons before initiating therapy.
Consider worst case: Consider what might be the greatest risk to patient safety.
Turn to others: Seek input from colleagues.
a Developed at University of California, Davis
The most impactful strategy for medical error reduction is analysis of previous errors, thus illustrating the importance of error reporting. Root-cause analysis and identification of contributing factors can facilitate development of interventions and policy to reduce the risk for similar future occurrences.6,8,10
Conclusion
Medical errors are underreported by an estimated 70% to 90% in human medicine and, although difficult to quantify, may be similarly underreported in veterinary medicine, representing a need for continued progress in reporting.4,8,11 Education on medical error awareness, client communication strategies, and safety culture can help develop these skills in both veterinary students and practicing clinicians.