Errors and critical events
Recognition and analysis of errors and the events and factors leading to them is an active area of current veterinary research. Errors may arise due to human, equipment, systems and processes failures. Single errors may not lead to a critical event, described as when there is a demonstrable effect on patient safety and outcome. Multiple errors, though may result in patient morbidity or mortality, with the ‘Swiss cheese’ model representing the requirement for a series of factors to ‘line’ up with each other and lead to a critical event. With errors and critical events comes blame, something that the veterinary profession is working to understand more effectively, with the RCVS, BVA and BSAVA all contributing to changing the ‘blame culture’ in the profession. When an individual is blamed for a critical event, there is most likely an underlying systems and processes failure that requires addressing and the individual error merely ‘lined up’ the final hole in the cheese. It is easy to become complacent in our roles at work and despite being sure about not missing steps in a process, it is easy to omit a critical step, when for example under pressure or tired. Complacency plays a large part in the evolution of compromised patient safety, along with poor communication and processes failures. These factors and cultures are all something checklists aim to minimise or even eliminate.
Safety checklist history
The airline industry introduced checklists to improve safety and reduce the incidence of human error leading to a catastrophic event. Safety checklists are now present for virtually every type of procedure, in every aircraft and are followed and signed off by the flight crew prior to take off. They detail all procedures from those required for taxi, take off, the cruise and landing, through to action in the event of an emergency. They are short, simple lists, involving only a small number of steps, thus maximising compliance and ensuring rapid completion. They act as an important aide memoire, aiming to ensure no step is omitted, thus reducing human error and avoiding complacency.
Another area the airline industry has worked to improve is communication within the flight deck. Non-essential conversation is not allowed below 10,000ft and all members of the flight crew address each other by first name only, removing any perceived hierarchy. This is an important area and may be applied into medical and veterinary practice to ensure team concentration at important time points, such as induction of anaesthesia.
A US medical doctor, Atul Gawande was pivotal in the development and introduction of the World Health Organisation (WHO) surgical safety checklist, following his observation of the vast benefit to the airline industry. The WHO checklist is now routinely used in all NHS hospitals in the UK and extensively worldwide. Although when first introduced it came up against fierce opposition, it has gradually become widely accepted. The WHO checklist has a pre-surgery/anaesthesia section, a time out section before first surgical incision and a post-surgery/recovery section. Each of these requires the surgical team to stop, run through a short list of steps and then continue. It includes simple procedures such as checking patient identity, ensuring the correct procedure is to be performed and that pre-first incision antibiosis has been administered. There is also an implementation booklet to accompany its use.
The WHO checklist was formally introduced in 2008. Following this, the Safe Surgery Saves Lives (SSSL) initiative was developed. The figures reported from 2009 showed a reduction in patient mortality from 1.5% to 0.8% following the introduction of the checklist. As safety culture awareness has increased in human medicine, the veterinary medicine community has begun to follow a similar pathway with the introduction of a number of checklists, for anaesthesia and surgery and an increase in the evidence base available to back up the benefits to our patients.
WHO Safe Surgery Saves Lives
The WHO SSSL campaign was developed by a working group set up to improve surgical safety. The working group reached consensus on four areas aiming to improve mortality and morbidity rates associated with surgery. The initiatives closely follow the principles behind the surgical checklist and has helped to form the basis for the development of subsequent checklists. The areas the campaign focuses on are:
- surgical site infection prevention
- safe anaesthesia
- safe surgical teams
- measurement of surgical services
The SSSL campaign has reduced overall complications associated with human error by 33%. The WHO has also introduced a pulse oximetry project into low and middle-income countries to improve the standard of anaesthetic monitoring.
Anaesthetists’ non-technical skills (ANTS)
The terms ANTS is used to describe the non-technical or cognitive and behavioural skills considered to be most important in the delivery of safe anaesthetic practice. There are four categories in the ANTS framework, situation awareness, decision making, task management and team working. These are skill areas that have been identified to be key in the anaesthetist’s ability to recognise and assess their own and others behaviour in clinical situations when good team work, communication and decision making are required. The Royal College of Anaesthetists currently offers this programme to medical anaesthetists in the UK.
What is a safety checklist?
A safety checklist is a tool designed to reduce patient morbidity, mortality and to improve communication between members of the veterinary team. They have been shown to be of particular use in busy, often stressful working environments, where teams are responsible for provision of patient care. They consist of sections, each with a set of questions, for example prior to induction of anaesthesia, prior to commencing the procedure and at the end of the procedure, before recovery. They are designed with a limited number of elements, allowing quick completion and most importantly to be relevant to the situation. One person should be assigned to reading the steps out to the team and recording responses, ensuring compliance and good record keeping.
Benefits of checklists
We’re all human! Communication is central to improving patient outcome, and checklists have been shown to improve this component of patient care across the medical and veterinary professions. Human error is reported to be responsible for over 50% of anaesthetic related death in human medicine and it is likely to be similar in veterinary medicine. It is often a small isolated step, such as a closed APL valve on a breathing system, that is missed leading to a chain of events, with the end-point being either serious harm or death. Checklists are designed to eliminate the need to memorise every single step of a protocol and therefore self-limit any errors that may eventually lead to a fatal or near-fatal incident. The checklist helps to ensure preparation prior to a procedure is thorough and specific patient factors are taken into consideration, which can be the difference between successfully dealing with an emergency situation and patient harm.
The introduction of a safety checklist is very likely to come up against some resistance, with fear of change often expressed by members of staff who may feel it unnecessary. This is usually a short-lived response and eventually the majority come to embrace its use.
Checklists should be designed to engage with the entire team and encompass the most important aspects of an individual practices concerns. A single checklist is therefore unlikely to be suitable for all practices but, following introduction they are easily adapted to ensure maximum benefit and team compliance.
The Association of Veterinary Anaesthetists (AVA) has developed an anaesthesia checklist and accompanying implementation booklet. The aim of this is increase awareness of and improve safety in veterinary anaesthesia. The AVA checklist is a free, downloadable resource. The Royal College of Veterinary Surgeons (RCVS) has included this in their requirements for the Practice Standards Scheme (PSS). The AVA has recently launched a “Safer Anaesthesia” project which aims to increase owner, veterinary nurse and veterinary surgeon awareness of the importance of good patient safety during the peri-anaesthetic period.
Introducing safety checklists into practice
Successful implementation of a safety checklist can be challenging and requires good team training prior to its introduction to aim for maximum compliance. Although there are published checklists available, they are generic and may require editing to ensure they work in an individual practice. It can be useful to carry out an initial audit to determine the important areas to focus upon. Although this article focusses on anaesthetic safety checklists, they can be tailored to any clinical situation that may require their use. They are also not just for use prior to a surgical procedure, rather prior to any procedure that requires anaesthesia.
Steps to consider
- Confirm patient identity
- Confirm procedure
- Communicate patient risk factors
- Has all equipment for induction and maintenance of anaesthesia been checked?
- Any specific patient or procedural requirements
- Confirm individual team member roles
- Pre-procedure commencing
- Re-confirm patient identity
- Re-confirm procedure
- Communicate concerns of anaesthesia and surgical/procedure teams
- Any special steps or equipment required
- Introduction of team members
- Recovery plan and person responsible
- Analgesia plan
- Patient concerns
- Record any significant events
- Any samples to be submitted and person responsible
Most importantly the checklist must be simple and allow for quick completion at the necessary time points. It should be designed to ensure each step is completed at the correct time and that team members involved in the procedure are present for their respective parts. This incorporates the importance of good communication into checklist completion.
Using a safety checklist
Each step should be completed at the appropriate time and members of staff involved in the procedure should be present if appropriate. The checklist should be read out aloud by one member of staff and the responses completed by another member of staff. Prior to the procedure commencing it is important that as many people as possible that will be involved with the patient’s care are present for its completion. Prior to recovery, the post-operative plan is completed, including analgesia if appropriate. Completion of the checklist should be recorded on the anaesthetic record or in the patient file.
As checklists are used more widely in veterinary practice they will become a part of normal practice, ensuring good team work, communication and patient safety.
Armitage-Chan, E.A., 2014. Human factors, non-technical skills, professionalism and flight safety: their roles in improving patient outcome. Veterinary Anaesthesia and Analgesia. 41, 221-223.
Hofmeister, E.H., Quandt, J., Braun, C., Shephard, M., 2014. Development, implementation and impact of simple patient safety interventions in a university teaching hospital. Veterinary Anaesthesia and Analgesia. 41, 243-248.
Ludders, J.W., McMillan, M., 2017. Errors in Veterinary Anesthesia (1st edn). Wiley-Blackwell, Oxford, UK.
McMillan, M., Brearley, J., 2013. Assessment of the variation in American society of anesthesiologists physical status classification assignment in small animal anaesthesia. Veterinary Anaesthesia and Analgesia. 40, 229-236.
McMillan M., 2014.Checklists in veterinary anaesthesia: why bother? Veterinary Record. 556-559.
Menoud, G., Axiak-Flammer, S., Spadavecchia, C., Raillard, M., 2018. Development and implementation of a perianesthetic safety checklist in a veterinary university small animal teaching hospital. Frontiers in Veterinary Science. 6, 60.
Originally published: Thursday, 30th August 2018
Last updated: Friday, 14th September 2018
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