Critical incidence reporting systems – an option in equine anaesthesia? Results from a panel meeting

A narrative review of the impact of work hours and insufficient rest on job performance

OBJECTIVE

This review discusses the scientific evidence regarding effects of insufficient rest on clinical performance and house officer training programs, the associations of clinical duty scheduling with insufficient rest, and the implications for risk management.

STUDY DESIGN

Narrative review.

METHODS

Several literature searches using broad terms such as "sleep deprivation," "veterinary," "physician," and "surgeon" were performed using PubMed and Google scholar.

RESULTS

Sleep deprivation and insufficient rest have clear and deleterious effects on job performance, which in healthcare occupations impacts patient safety and practice function. The unique requirements of a career in veterinary surgery, which may include on-call shifts and overnight work, can lead to distinct sleep challenges and chronic insufficient rest with resultant serious but often poorly recognized impacts. These effects negatively impact practices, teams, surgeons, and patients. The self-assessment of fatigue and performance effect is demonstrably untrustworthy, reinforcing the need for institution-level protections. While the issues are complex and there is no one-size-fits-all approach, duty hour or workload restrictions may be an important first step in addressing these issues within veterinary surgery, as it has been in human medicine.

CONCLUSION

Systematic re-examination of cultural expectations and practice logistics are needed if improvement in working hours, clinician well-being, productivity, and patient safety are to occur.

CLINICAL SIGNIFICANCE (OR IMPACT)

A more comprehensive understanding of the magnitude and consequence of sleep-related impairment better enables surgeons and hospital management to address systemic challenges in veterinary practice and training programs.

Application of systems analysis to safety incident investigations in a single centre using anaesthesia as an example

BACKGROUND

Systems analysis is widely recommended for patient safety investigations in medicine, but the method is poorly described in the veterinary literature.

METHODS

Anaesthetic safety incidents were discussed in debriefs and then reported on standardised forms. Investigators performed informal interviews with team members involved in case management and interrogated clinical records. Finally, incidents were discussed during morbidity and mortality conferences. Systems analysis involved developing a timeline for the case, identifying any care delivery problems (CDPs) that occurred and contributing factors associated with them, and developing control measures to reduce system weaknesses.

RESULTS

From 15 incidents, 32 CDPs were identified. These were categorised into 11 thematic groups. Misdiagnosis (n = 8), human resource allocation (n = 8), failure in planning (n = 6) and technical error (n = 5) were most frequent. Individual factors were identified in 15 (100%), team factors in 12 (80.0%), animal and owner factors in 11 (73.3%), organisation factors in 10 (66.7%), work environmental factors in 10 (66.7%) and task and technology factors in four (26.7%) investigations. Numerous immediate and longer term recommendations were made regarding how to manage systems weaknesses.

LIMITATIONS

Investigations were limited to pre-procedural anaesthetic safety incidents.

CONCLUSIONS

Systems analysis applied to incident investigations can highlight areas for improvement within veterinary healthcare systems.

Using the critical incident technique to determine veterinary professional competencies important for enhancing the veterinarian-client interaction

BACKGROUND

While previous research has examined components of professionalism that veterinary employers and clients expect in veterinarians, little attention has been paid to practising clinical veterinarians' opinions on important professional competencies that help to enhance the veterinarian-client relationship. This study used a phenomenological approach and critical incident technique to gather the narratives of practising veterinarians in New Zealand about positive and negative veterinarian-client interactions. The intention was to identify the underlying principles of professionalism that resulted in the positive/negative outcomes of those interactions.

METHODS

Twenty-two practising veterinarians were interviewed, and each respondent was asked to recollect and narrate a significant positive and a significant negative critical incident in their career that involved a veterinarian-client interaction within a clinical setting. The professional competencies that the veterinarian believed contributed to a successful or an unsuccessful outcome were elucidated using thematic analysis.

RESULTS

Thematic analysis of the critical incident narratives revealed four major themes under the overarching theme of 'building a relationship between the veterinarian and the client': 'accountability and integrity', 'effective communication skills', 'personal wellbeing' and 'quality of care'.

CONCLUSION

The description of the important professional competencies that helped to enhance the veterinarian-client relationship provides a reference for the practising profession to help improve the likelihood of veterinarians enjoying satisfied and successful careers.

Development of incident severity classification for laboratory animals

An incident reporting system (IRS) prevents possible adverse events by collecting and analyzing incidents that occur. However, few studies are available regarding IRSs in the laboratory animal field. This study aimed to develop an incident severity classification for laboratory animals (ISCLA) to evaluate the usefulness of the IRS in laboratory animal facilities. Twenty-three incidents reported from March 2019 to February 2020 on our IRS were retrospectively reviewed. Three of the 23 incidents failed to obtain some experimental data. Two of these incidents were harmless to animals, but the other caused the animals moderate distress. In addition, two of the three incidents made animals unsuitable for experiments. Since the inconsistent impact of incidents on animals and experiments prevented the comparison of the severity of individual incidents, we developed the ISCLA. According to the ISCLA, the above three incidents were classified into Category 3b and 4a. The others were classified into Category 0 (n=5), 1 (n=6), 2 (n=3), and 3a (n=6) in ascending order of severity. No incident was classified into Category 4b and 5. Furthermore, incidents occurring in the animal housing area were more severe than those occurring in the supporting area (P=0.002). This study showed that incident occurrences had characteristics that were not visible from individual incidents alone. Moreover, the ISCLA was considered useful when conducting the IRS and taking improvement measures in laboratory animal facilities.

Investigating the Effects of Error Management Training versus Error Avoidance Training on the Performance of Veterinary Students Learning Blood Smear Analysis

Conventional veterinary training emphasizes correct methodologies, potentially failing to exploit learning opportunities that arise as a result of errors. Error management training (EMT) encourages mistakes during low-stakes training, with the intention of modifying perceptions toward errors and using them to improve performance in unfamiliar scenarios (adaptive transfer). Herein, we aimed to determine the efficacy of EMT, supplemented by a metacognitive module, for veterinary students learning blood smear preparation and interpretation. Our hypothesis was that EMT and metacognition are associated with improved adaptive transfer performance, as compared with error avoidance training (EAT). A total of 26 students were prospectively enrolled in this double-blind study. Performance was evaluated according to monolayer area, smear quality, cell identification, calculated white blood cell differential counts, and overall application/interpretation. Students were trained with normal canine blood and static photomicrographs. Participants tested 72 hours after training demonstrated improved performance in a test that directly recapitulated training (Wilcoxon matched-pairs signed-rank test; two-tailed p all ≤ .001). There were no significant differences between EAT and EMT in this test (Mann-Whitney U test and Welch's t-test; two-tailed p ≥ .26) or in short- and long-term adaptive transfer tests (p ≥ .22). Survey data indicate that participants found errors to be a valuable element of training, and that many felt capable of accurately reflecting on their own performance. These data suggest that EMT might produce outcomes comparable to EAT as it relates to blood smear analysis.

Blame and shame in the veterinary profession: barriers and facilitators to reporting significant events

Significant event reporting is an important concept for patient safety in human medicine, but substantial barriers to the discussion and reporting of adverse events have been identified. This study explored the factors that influence the discussion and reporting of significant events among veterinary surgeons and nurses. Purposive sampling was used to generate participants for six focus groups consisting of a range of veterinary professionals of different ages and roles (mean N per group=9). Thematic analysis of the discussions identified three main themes: the effect of culture, the influence of organisational systems and the emotional effect of error. Fear, lack of time or understanding and organisational concerns were identified as barriers, while the effect of feedback, opportunity for learning and structure of a reporting system facilitated error reporting. Professional attitudes and culture emerged as both a positive and negative influence on the discussion of error. The results were triangulated against the findings in the medical literature and highlight common themes in clinician's concerns regarding the discussion of professional error. The results of this study have been used to inform the development of the 'VetSafe' tool, a web-based central error reporting system.

The Effect of Simulation Training in Anesthesia on Student Operational Performance and Patient Safety

A veterinary anesthesia simulated environment (VASE) with clinical scenarios has been integrated into the pre-clinical curriculum at Midwestern University College of Veterinary Medicine to simulate anesthesia of a live patient within a surgical suite. Although this modality was shown to significantly improve veterinary students' perceived preparedness to perform anesthesia on live patients, whether this would improve anesthesia competency in the actual clinical environment, described as operational performance, remained unclear. Our goal was to examine the relationship between anesthesia simulation training and student anesthesia operational performance. Anesthesia operational performance assessment of students was determined by quantifying critical event occurrences that negatively impacted patient safety during the anesthesia of 287 patients during students' initial surgical experience in 2015 and 2016. The relationship between total numbers of critical incidents to students having anesthesia simulation training was determined through evaluation of anesthesia records from 2015 and 2016, where students did not have anesthesia simulation training or they had pre-clinical training, respectively. Results showed a significant relationship between simulation training and critical incident occurrence, with a critical incident more likely to occur during patient anesthesia for students who did not experience pre-clinical anesthesia simulation training. Of the total critical incidents that occurred in the two-year study, 88% were in patients anesthetized by students who did not have simulation training. Our findings suggest that students who were given the opportunity to participate in anesthesia-focused simulations before a live-animal anesthesia encounter demonstrated significant improvements in anesthesia operational performance and improved patient safety.

Critical incident technique analysis applied to perianesthetic cardiac arrests at a university teaching hospital

OBJECTIVE

To apply the critical incident technique (CIT) methodology to a series of perianesthetic cardiac arrest events at a university teaching hospital to describe the factors that contributed to cardiac arrest.

STUDY DESIGN

CIT qualitative analysis of a case series.

ANIMALS

A group of 16 dogs and cats that suffered a perioperative cardiac arrest between November 2013 and November 2016.

METHODS

If an arrest occurred, the event was discussed among the anesthesiologists. The discussion included a description of the case, a description of the sequence of events leading up to the arrest and a discussion of what could have been done to affect the outcome. A written description of the case and the event including animal signalment and a timeline of events was provided by the supervising anesthesiologist following discussion among the anesthesiologists. Only dogs or cats were included. After the data collection period, information from the medical record was collected. A qualitative document analysis was performed on the summaries provided about each case by the supervising anesthesiologist, the medical record and any supporting documents. Each case was then classified into one or more of the following: animal, human, equipment, drug and procedural factors for cardiac arrest.

RESULTS

The most common factor was animal (n=14), followed by human (n=12), procedural (n=4), drugs (n=1) and equipment (n=1). The majority (n=11) of animals had multiple factors identified.

CONCLUSIONS AND CLINICAL RELEVANCE

Cardiac arrests during anesthesia at a referral teaching hospital were primarily a result of animal and human factors. Arrests because of procedural, drug and equipment factors were uncommon. Most animals experienced more than one factor and two animals arrested after a change in recumbency. Future work should focus on root cause analysis and interventions designed to minimize all factors, particularly human ones.

Development, implementation and impact of simple patient safety interventions in a university teaching hospital

OBJECTIVE

To determine the incidence of anesthesia patient safety incidents at a university teaching hospital, develop interventions to address the most common incidents, and determine the effectiveness of these interventions.

STUDY DESIGN

Pre-post intervention observational.

ANIMALS

Four thousand, one hundred forty dogs and cats anesthetized by the anesthesia service.

METHODS

The study was divided into two 11.5 month periods. During each period, incidents were logged (e.g. closed adjustable pressure limiting (APL) valve, esophageal intubation, and medication error). At the end of the first period, four countermeasures were incorporated into the service's protocols: 1) prior to any drug injection, the individual would read out aloud the drug name, patient name, and route of administration; 2) use of a uniquely colored occlusive wrap over arterial catheters; 3) a check box on the anesthesia record labeled "Technician Confirmed Intubation"; 4) a check box on the anesthesia record labeled "Technician Checked OR (operating room)". The number of patient safety incidents during period 1 and period 2 were compared using Fisher's Exact Test.

RESULTS

During Period 1, there were 74 incidents documented in 2028 patients (3.6%) including 25 medication errors, 20 closed APL valves, and 16 of esophageal intubation. During Period 2, there were 30 incidents documented in 2112 patients (1.4%) including 14 medication errors, 5 closed APL valves, and 4 of esophageal intubation. The proportion of events during Period 2 was significantly smaller than during Period 1 (p < 0.0001).

CONCLUSIONS AND CLINICAL RELEVANCE

Implementation of four simple interventions was associated with a significant decrease in the number of incidents.