In my last article, “When intuition fails” (VT49.13), I discussed a case where pattern recognition had led me astray – due to recognising the wrong pattern.
If you have read my articles, you may have noticed – while clinically, I enjoy internal medicine, emergency and critical care, and imaging – one of my key areas of interest is education and development. I am a classic veterinary geek – I love learning and learning about learning.
Morbidity and mortality
One of my recent endeavours at Leonard Brothers Veterinary Centre was to introduce morbidity and mortality conferences/rounds (M and Ms). At this point, I would like to direct readers to the fantastic article by Pang et al (2018). To put it briefly, M and Ms involve a formal discussion on adverse events in practice.
M and Ms are common practice in human medicine and have become a part of the RCVS Practice Standards Scheme, although, as a result, are not mandatory for all veterinary surgeries. With up to half of the adverse events in human medicine being preventable, it is understandable why such a huge focus on M and Ms to improve patient care exists.
It is not that far a stretch to imagine a similar proportion of preventable error in veterinary medicine and I, for one, think it is our duty as members of the RCVS to try to recognise these preventable errors, and get to work on preventing them.
Implementing M and Ms does require a, sometimes difficult, change in mindset. Often, we are so emotionally tied to our clinical competence any suggestion of error can set off a cascade of excuses, defensiveness and, at times, anger. We all got into this profession to help improve animal welfare, so it is understandable any discussion of adverse events can lead to this defensive response. However, one key issue exists with getting on the defensive; the mistake has already been made, we can’t change that. If we do nothing, the mistake can happen again and again, and again. However, if we recognise the mistake and, more importantly, learn from it, we can prevent further harm to our patients and improve our overall patient care. This must be the goal of M and Ms. They aren’t an opportunity to sit around and blame each other, as this will only lead to further defensiveness, but they are an opportunity to bring up issues in a safe environment to help improve patient care.
Given the inevitability of human error, mistakes are going to happen – whether it be a 10 times overdose of an IV pre-med, doing an orthopaedic operation on the wrong leg, or even a breakdown in communication with a client and subsequent complaints over finance – we might as well take something positive from it.
Inaugural M and M conference
Being a relatively new vet, with no prior experience of M and Ms, I found chairing our first meeting quite daunting. However, the aforementioned article (Pang et al, 2018) details a great format for keeping people on track and making the most of the shared learning experience.
Starting off with stating the goal of improving patient care and making sure each member of the team knew why we were there, I got to presenting the first case (after the required clinical meeting takeaway had been consumed, of course). For obvious reasons, I won’t be detailing the individual cases discussed; however, the format taken from Pang et al (2018) can be applied.
SBAR model
Most of us find structure comforting, so standardising the format of a delicate meeting can help take the pressure away from the individuals attending. Pang et al (2018) recommend the following SBAR format (an example case is given to aid explanation):
- Situation: a brief summary statement of the identified problem. For example, a routine bitch spay received a 10 times overdose of buprenorphine.
- Background: history, preparation prior to adverse event, description of the event. For example, a six-month-old female cairn terrier presented for routine ovariectomy. A vet responsible for the case decided to premed with acepromazine and buprenorphine at 0.02mg/kg IM. The vet involved had only recently dealt with methadone pre-meds for such procedures, and confused the 0.02mg/kg dose with the 0.2mg/kg used for methadone. The dog was premedicated without the dose being double-checked. At anaesthetic induction, it was noted the dog was much less responsive than expected. The doses were checked and 10 times overdose was found to have occurred. The dog received an appropriate dose of naloxone and was monitored for the next few hours.
- Assessment (and analysis): what led to the issue? For example, the practice would usually double-check all of the doses, but, unfortunately, it was a particularly busy morning so this was missed in an effort to save time. The dose was not double-checked and the dog was administered an overdose.
- Review the literature: what is the latest evidence-based veterinary medicine? For example, a recent comparison of buprenorphine versus methadone in dogs undergoing elective ovariohysterectomy found a significantly higher need for rescue analgesia in dogs premedicated with buprenorphine (Shah et al, 2018).
- Recommendation: prevention of recurrence. For example, the practice decided the premedication section of the anaesthesia form would follow the format below:
- Dose rate (mg/kg)
- Total dose (mg/kg × bodyweight[kg])
- Drug concentration (mg/ml)
- Drug volume (total dose/drug concentration)
- All drugs to be checked by at least three people to prevent further medication errors.
- All bitch spays to have methadone as standard, not buprenorphine.
The above scenario is just one example of a very common adverse event that can easily be prevented. Arguably, the most important part of the above process is the recognition of the adverse event in the first place, but, once recognised, having a standard approach to root cause analysis can direct the team away from a culture of blame and towards a culture of improved patient care.
I am happy to say our first M and Ms were a success and each member of the team found it to be a useful experience. While we have regular clinical meetings where protocols, new plans and recent CPD is discussed, as well as meetings with the medics and the surgeons, it is my hope regular M and Ms will provide a new opportunity for learning and growth as a practice.
Ward rounds
A second recent introduction to the daily routine at Leonard Brothers is ward rounds. I am sure all of my readers remember the daily rounds at veterinary school, where we would present cases and clinicians would quiz us on certain aspects of the case. Although at the time these may have felt incredibly daunting, their inclusion in the day-to-day teaching was strategic and invaluable. We all learn in different ways, but, for me, learning about a topic while relating it to an individual case provides the best short-term and long-term connections to retain as a memory.
We decided to implement daily ward rounds to improve our handover of cases and general in-patient care. For us, ward rounds take place at 3:30pm, which is a “protected time” with no consults booked (pending emergencies) and all members of staff directly involved with patient care attend. Initially, obvious concern was raised about increasing workload for some members of staff, taking away from consulting time and their overall “usefulness”.
Each case is discussed by the members of the team involved. Each case, therefore, has at least three people commenting on it (patient care assistant, RVN, vet) and it has allowed us to organise the day better (to-go-home times, feeding instructions, IV catheter removal, owner financial updates), as well as pick up minor issues that are then discussed among the team.
A practical example was regarding our internal trial; comparing acepromazine and medetomidine premedication for routine neutering as a result of the isoflurane shortage. Members of the team have been coming forth detailing the overall anaesthetic quality and opinions on changing to medetomidine, and the ward rounds have proved very useful in our clinical audit of the change. I can say with all honesty, the team have found them to be a great addition to the day. Of course, we have had days where emergencies have interrupted or entirely precluded ward rounds, but these have been the minority.
We have also had days where there have been very few in-patients or ops, so this has allowed protected time for in-house CPD (such as our recent workshops on CPR) or generic “catch-up” time.
For readers apprehensive about introducing M and Ms and ward rounds into their practices, what do you have to lose? I urge you to trial both of the aforementioned tools and I am sure you will find them as useful as we have. They can help improve patient care and only require minimal effort – the biggest effort comes in accepting their necessity.
I would like to hear from anyone who has decided to implement similar procedures as I really believe they can be instrumental in improving the service we provide to our patients and our clients.
That’s all folks!
If you have a question, or want to discuss a topic from Practice Makes Perfect, email me at dbeeston2@rvc.ac.uk and I will get back to you ASAP. Until next time, take care.