It's not just Human medicine that is impacted by Human Error
Teresa Mullen
Passionate Organisational and Operational Learning Consultant, Key Note Speaker and Executive Coach.
Our pets can't tell us what's wrong so it's even more important for our Vets to get it right!
For full disclosure I am not a vet! However the work I do in other sectors is extremely relevant to this sector and so the purpose of this article is to raise awareness that the level of thinking about human error outside of your veterinary practice, has advanced and you might want to think about reviewing your approach to human error
Like many of you I am a pet lover. I currently own 2 crazy Springer Spaniels and a Cleveland Bay horse, not to mention a grumpy cat and some tropical fish I seem to have adopted from my Son! I grew up in a pet-loving home surrounded by animals of all shapes and sizes; my animals have always been treated and considered a part of the family and so when they are sick it is important for me to know that I have the right professionals on-hand to take good care of them, after all, they can't describe their symptoms or tell me where it hurts. I also want to be assured that when in their care, my pets are protected from the potential consequences of errors made during their treatment.
I have recently had a few visits from my Equine Veterinary Practitioner as my lovely mare Rosie, who is 17 went lame. I am very fortunate in that this vet is highly experienced and competent and so I know that my girl is in safe hands but that doesn't mean that she could never be a victim of a human error, in fact there is probably more chance of her experiencing a medical or surgical error than me.
Just like in Human medicine, in the world of veterinary surgery the reality of human error casts a long shadow. Mistakes happen, and they can have significant consequences for animal patients.
In their 2019 paper, Medical Errors Cause Harm in Veterinary Hospitals, Jessica Wallis, Daniel Fletcher, Adrienne Bentley and John Ludders conducted a study of 560 medical errors reported in three veterinary hospitals between February 2015 and March 2018. The incidents were classified as a) Near miss, b) Harmless hit, c) Adverse incident, or d) Unsafe condition.
The study identified that 15% of all incidents resulted in patient harm. Eight percent of patients harmed suffered permanent morbidity or death. They concluded that medical errors have a substantial impact on veterinary patients.
While the image of the Veterinarian with unwavering focus and deep-rooted expertise is often portrayed, the truth is that veterinary professionals are human, and therefore, just as fallible as the rest of us.
As with human medicine, a number of factors contribute to human error in veterinary practice:
The consequences of these errors can range from minor complications to life-threatening situations. Surgical site infections, incorrect dosages of anaesthesia, and even "wrong-side" surgeries are all potential outcomes of human error, but it's important to remember that these mistakes are rarely the result of negligence or incompetence.
The veterinary community is increasingly recognising the importance of addressing human error but the first step is to understand what it is, and then why and when it occurs, before we can do something about it.
Medical Error
A medical error has been defined as “an act of omission or commission in planning or execution that contributes or could contribute to an unintended result” (Grober ED, Bohnen JMA. (2005) 48:39–44.1).
Human error is not a conscious choice to make a mistake, but rather a lapse in attention, judgment, or skill.?Another way of describing human error in layman's terms is "Something I didn't intend to do".
Types of errors
In his 2000 paper Human error: Models and management, James Reason defined three types of human error:
Why does it happen?
Making errors is simply part of being a human. Our brain, despite being a wonder of science, is actually very lazy. Each of us has our own unique filing system which deletes, distorts and generalises the information it receives in order for us to make sense of it by comparing it to an existing personal belief or set of principles. How your brain processes information will be very different to how mine does due to our backgrounds, personal values, life experiences, etc..
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The lazy brain is then put to work in a complex environment where organisational systems, established norms of group behaviour and complicated processes and procedures can be flawed, incomplete or inadequate. This melting pot of distractions, challenges and our often limited cognitive capacity increases our propensity for error, putting us in an 'error-likely situation'.
When does it happen?
Error precursors such as poor instructions, confusing displays, inadequate training, insufficient staffing, or flawed protocols, etc. can provide an indication that we are in an 'error-likely' situation. Think about the last error you remember making - it might have been something as simple as being unable to find your reading glasses, only to realise they are sitting on your head. If you could replicate this you would undoubtedly come up with a number of error precursors that combined to increase the likelihood, perhaps you were distracted from reading due to a phone call, or somebody came to speak to you while you were writing a report.
Thankfully a minor error such as this doesn't usually result in a significant adverse consequence, indeed the majority of errors that you make have no consequence whatsoever and that's what makes them hard to remember and address! Unfortunately however some errors do result in adverse consequences. According to Wallis et al. (2019) medical errors occur frequently in veterinary hospitals, with approximately five errors reported per 1,000 patient visits (across the three practices involved in the study). Sadly, you cannot eliminate error from your 'system', it's a bit like gravity - you need to adapt and work with it; punishing, shaming and penalising people for making errors has little to no long-term effects or benefits, in fact it can have the exact opposite effect and push error reporting underground.
Research from the Nuclear Industry in 2012 suggests that people make, on average, 5 errors per hour, therefore if you are unable to eliminate error you must instead shift your focus to a) removing the factors that increase the likelihood of them, and b) reducing the consequences of them once committed.
How do you predict human error?
Error-likely situations are predictable, manageable and preventable. This is good news for all of us. Despite your individual uniqueness, humans are relatively consistent and your behaviours in the face of certain stimuli are pretty predictable, think about your natural inclination to break when your car starts to slip on ice and snow. The automotive industry is an exemplar in understanding human error and reducing the consequences of it. Take a look at your own car the next time you get in and list all of the functions that are built in, not to prevent you making errors, but to prevent your error becoming a disaster; from seat belts to lane assist. Their knowledge gleaned from many years of data and studies of driver (and pedestrian) behaviour enables them to stay ahead of the curve and design systems that absorb human error. How can you apply this level of thinking to your work?
Removing error precursors and reducing the consequence of error
You cannot hope to deal with human error unless you elevate your thinking to a 'system' level. Where is your system (the corporate body, the leadership, the culture, the rules, policies and procedures, etc.) setting you up to fail?
Are your protocols too bureaucratic? Are your standard operating procedures incorrect or incomplete? Do you have the right people in the right roles? Do you have alignment across the business? Are you measuring and reinforcing the right things? All of these things drive individual behaviour in the workplace, both good and bad.
What is the worst thing that could happen and what will you do when it does? How can you prevent your molehill turning into a mountain? Having challenging conversations about worst-case scenarios is never easy but critical if you want to identify and eliminate the things that set you up to fail. Too often these conversations are had at the wrong end of a bad outcome, when you don't typically have the benefit of sound judgement and strong decision-making skills.
Start with what's important
Addressing Human Error requires a constantly vigil mindset focused on removing the barriers that increase your collective error propensity but you cannot eat the elephant whole. Start with your biggest risks - there is evidence (Wallis et al (2019)) that medication errors, i.e. incorrect dosage or incorrect timing of dose, is one of the biggest risks in this sector. Assess the likelihood of your team making errors in your practice. Can you implement more stringent controls? Can you use peer-check systems? Can you automate any part of the process? Can you harness technology? How can you ensure that your people are not distracted when prescribing or administering drugs? What are your other 'critical risks'? How well are you controlling those? Reducing the biggest risks firsts and adopting an 'error avoidance' mindset will set you up for success as you continue down through your less risky activities. A 'healthy unease' is a good mantra to adopt for how people should feel when they are undertaking a critical risk task or activity.
Talk to your people
Your people are the key to identifying and eliminating error precursors because they are currently dodging, ducking and diving to work around them successfully every day, therefore they are often the best place to start! Ask your team what increases the likelihood of them making errors and what would they do if they could fix it? Be curious and don't assume that you or the most senior person in the practice has all the right answers. Listen to your people - their perceptions are their reality, if they tell you there's an issue, don't dismiss it - deal with it.
So what next?
I am very happy with the veterinary practices that support me and my pets right now and I am confident that my animals are safe in their care but I know that there is always a risk that a 'simple error' could result in a bad outcome. I would love to see more veterinary practices focusing on 'managing' human error, rather than the misguided mission of 'eliminating' it. If you would like to find out more please reach out or visit our website www.getthegrit.com or attend one of the many free opportunities we are providing in 2025 to raise awareness of our field of expertise.
Coach @ PrimeCoach | Certified RQI practitioner, EMCC certified coach
1 个月You should speak to Dan Tipney from VetLed this is their area of expertise and work.
Dir of L&D at GettheGRIT UK. Specialist in Human & Organisational Performance, Leadership, Human Factors | MSc MRAeS FInstLM FCMI
1 个月What a great article. It occurred to me that something vets often face is dealing with distressed owners while trying to care for the animal. This is particularly true for equine issues, as the owner is not in a waiting room but perhaps hovering closely, asking questions, offering solutions or in distress! Surely, this must be a huge cause of distraction.