Using medical errors as learning opportunities

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How are medical errors perceived in the veterinary profession and how should they be perceived? In their lecture at the 2024 American College of Veterinary Internal Medicine(ACVIM) Forum in Minneapolis, Minnesota, Melinda Larson, DVM, DACVIM, director of medical quality at BluePearl Pet Hospitals in Clearwater, Florida and Richard Stone, DVM, DACVIM, chief medical officer at BluePearl Pet Hospitals in Houston, Texas, spoke on the importance of instituting a culture and system within the health care profession that not only promotes open discussion of medical errors, but perceives these errors as learning opportunities.¹

Black box thinking and destigmatizing mistakes

At core of Larson and Stone’s lecture stood journalist, author, and broadcaster, Matthew Syed’s ‘black box thinking’ approach, illustrated in Syed’s titular book. As Larson and Stone explained, the aviation industry stores all cockpit voice and flight data recordings, formerly in a black box. When an incident occurs, these boxes are used to pinpoint where things went wrong, and the data is used to devise strategies for preventing similar events in the future.

Larson went on to emphasize this black box strategy in aviation be applied to health care. “Black box thinking [is described] as creating systems and cultures that enable organizations to learn from their errors rather than being threatened by them. It's really this learning mentality, this learning mindset, that is the core foundation—the science of patient safety,” she explained.

Stone talked about how certain words or phrases, such as ‘medical error,’ ‘adverse event,’ ‘near miss,’ ‘harm’ or ‘committed,’ and ‘error’ can “trigger people to put up their defenses,” resulting in an avoidance of discussing these events. To help eliminate some of this stigma, the presenters encouraged health care professionals to instead utilize the umbrella term ‘patient safety event,’ which does not carry the same negative connotation as other related terminology.

In their session, Larson and Stone discussed the prevalence of mistakes in health care. According to a 2016 study, patient safety events in human health care were the third leading cause of death in the United States.² Moreover, about 1 in 10 patients are harmed from an adverse event, with more than 50% of that harm being considered preventable.¹ Although there is limited literature on the frequency of errors in veterinary medicine, one study found that almost 74% of 606 veterinarians surveyed reported being involved in 1 or more near miss or adverse event, and more than 50% reported being affected by these events, both professionally and personally.^1,3

“Health care is so complex, whether that is human health care, veterinary health care, all of it—extremely complex—and therefore error provoking. Yet, health workers stigmatize fallibility and have little or no training in error management or error detection,” Larson said.

Systems thinking

As part of the ‘black box thinking’ approach, Larson and Stone elaborated on the usefulness of incidence reporting systems, which provide a way for team members to record any patient safety events that occur in the workplace. Much like airlines’ black boxes, this collection of data on each incident help organizations identity trends in these events, consequently providing opportunities.

Contrary to common belief, the majority of patient safety events are rarely the sole result of one individual, according to Larson and Stone. Rather, errors are multifaceted and a result of intricate systems that contain multiple factors that lead up to the event. “Medical errors are rarely as simple as a single person doing something wrong; people exist within systems,” said Larson. As such, Larson and Stone encouraged establishing ‘systems thinking,’ as this form of thinking is the foundation in learning and improving from patient safety events.

Once systems thinking is in place, “root cause analysis” may be applied. This term refers to the methodical and organized examination of medical errors aimed at pinpointing and making alterations to the system to decrease the chances of the same mistake reoccurring.

References

1. Larson M, Stone R. Finding the black box: Learning from medical errors. Presented at: American College of Veterinary Internal Medicine Forum; Minneapolis, MN; June 5–8, 2024.
2. Low R, Wu AW. Veterinary Healthcare needs to talk more about error: For the wellbeing of our patients and medical teams. Journal of Veterinary Internal Medicine. 2022;36(6):2199-2202. https://doi.org/10.1111/jvim.16554
3. Kogan LR, Rishniw M, Hellyer PW, Schoenfeld-Tacher RM. Veterinarians’ experiences with near misses and adverse events. J Am Vet Med Assoc. 2018;252(5):586-595. https://doi.org/10.2460/javma.252.5.586