What System(s) Does Your Practice Have in Place to Prevent Medical Errors?

In our November "In the Trenches" issue, EVT asked 3 veterinary professionals what their practices do to prevent medical errors—read their full interviews here!

Some of these ideas may surprise you. Others may be just what you've been considering for your practice all along.

Here's how these extraordinary practices have been making them work!

Three elements in particular truly help us at The Center for Animal Wellness in Denver. The 1st crucial element is good flow of communication, of always talking to each other. The 2nd is use of very specific written communication for 3 dedicated dry boards, each with its own checklist. The 3rd crucial element is final review by the doctor, who reviews the patient’s chart and the results of lab work (which is required to be conducted by the previous day) and checks with the technician to make sure that everything in the paperwork has been included or no new finding or information has just been discovered. It’s all about 1-on-1 communication!

We don’t rely on the written form only, but emphasize multiple levels of communication.

To expand on these elements that help our practice prevent medical errors:

#1

The 1st crucial element is a good flow of communication, of always talking to each other. That’s the 1st thing. The front desk staff talks to the technician on a particular subject, then the technician talks to the doctor, the doctor then talks to someone else on that same subject, and so on.

#2

The 2nd is that we do use written communication very specifically for 3 dedicated dry boards, with their own checklists. The Center has a dry board for prescriptions and follow-up testing, another for surgical, dental, and emergency cases, and lastly one for all in-house and lab tests. Regarding prescriptions for example, the doctors write out everything on the checklist each case carries, and the technician has to check and initial their work on it. A copy of the prescription label is also placed in the client’s file, with instructions that the receptionist then reviews with the client. We also use handouts as well with prescriptions, which the client appreciates.

#3

The 3rd crucial element is a final review from the doctor. The doctor reviews the patient’s charts and lab work (which is required to be done by the previous day), and checks in with the technician to make sure nothing extra is going on that might have not been stated in the paperwork or may have just been discovered.

Overall, the Center for Animal Wellness focuses on face-to-face communication, and lots of it! Written communication is used effectively and appropriately as well. This prioritizing has saved us a lot of trouble, and clients have greatly appreciated it.

Staff meetings

We also have weekly staff meetings on Thursday mornings. They are ALWAYS positive, and everyone contributes. All opinions are sought and valued. We discuss everything and anything. The Office Manager directs the meeting, and anyone can submit an item for the agenda, whatever it might be. The Center even has a checklist here too, which includes a check box for everyone to note they’ve been informed of the meeting checklist items.

Last but not least, the break room also has a general posting board. Just because we value 1-on-1 communication doesn’t mean we don’t know how to cover our bases with written communication!

We’re trying to go paper-light, as that seems to work best. But handwritten notes, however nice the writing is or isn’t, really are invaluable. Some things are better communicated on paper, not electronically.

The Center for Animal Wellness is also an AAHA-accredited practice, so their protocols really help us. We follow them rigidly! Everyone is required to review the AAHA protocols annually.

But as described above, at the heart of everything is 1-on-1 communication!
 

What’s special to NorthStar VETS, an emergency trauma and specialty hospital, is collaboration. We don’t look at the patient as belonging to one service or another; ophthalmology, surgery, internal medicine, and so forth all work together on each patient as an individual. We also do “cage-side” rounds twice a day, which is different from most hospitals our size. Every team member is involved; for instance, an ophthalmologist will weigh in on an internal medicine case. We have the advantage of all the specialties reviewing the case together. NorthStar VETS also has extensive checks and balances to make sure our procedures are consistent and systematic. We’re constantly improving our quality of care overall, not just avoiding medical errors.

The entire team communicates together clearly and carefully. We don’t look at the patient as belonging to one service or another; Ophthalmology, surgery, internal medicine, and so forth all work together on the individual patient. There’s a comprehensive check and balance regarding the patient. We make sure the clients are fully informed, so they can make the best possible decisions.

We have checks and balances to make sure our procedures are consistent and systematic.

For example, the checks and balances system for:

Anesthesia

When it comes to anesthesia at NorthStar VETS it’s a collective effort to make sure things run smoothly for the patient. We operate on a five-point system: doctor indicates the drug protocol, the technician reviews, a second technician draws up the medication, a third technician reviews and administers pre-meds, and finally a technician will monitor the patient while in a procedure. NorthStar VETS has two criticalists on the team who often consult on challenging anesthetic cases. If a patient’s having distress, they help troubleshoot the situation—just jump right in.

A similar system is equally comprehensive when a patient is going home. The doctor prescribes the medication, technician reviews, pharmacy technician prepares, the receptionist ensures meds match the label and finally the discharge technician reviews with the client. Everything is checked: drug volume, weight, whether it’s appropriate.

Cage-side rounds

We also do “cage-side” rounds, twice each day. NorthStar VETS is different from most other clinics in that regard. Most rounds elsewhere are typically done in a conference room; our rounds are done in front of the patient, with the treatment sheet right there. Everyone jumps in on these rounds, nurses included. For instance, an ophthalmologist will weigh in on an internal medicine case. We have the advantage of all the specializations reviewing the case together, creating a holistic advantage in the process. Which gives us a logistical advantage as well!

Our emergency trauma and specialty hospital has a color coded treatment sheet for every single case. We try to avoid to verbal orders, keep it to written communications—for example, exactly when to pull the catheter. The most minute details are included on the treatment sheet, which the technician initials and notes the time.

Additionally, ongoing training is key, both in-house and external training. We have always done extensive in-house training however, we recently kicked it up to a whole new level with a professional development coordinator on hand to help with the training.

All our records are electronic. Not paperless, but “paper-light.”

NorthStar VETS is constantly improving our quality of care, not just avoiding medical errors!
 

In general, you need to create a culture of teamwork and improvement. When you have the chance, write it down. Any time you write something down, such as with our treatment orders or pharmaceutical prescriptions, you have an opportunity to double-check it. The real solution to medical mistakes involves seeing where a problem might occur and preventing them in advance. It’s an “all hands on deck” approach – everyone participates! Every situation is a team situation. It’s one of our greatest strengths at Pet Emergency & Specialty Center of Marin and allows us to offer the best service possible to the community.

Specifically, 3 things in particular help the Pet Emergency & Specialty Center of Marin prevent medical errors:

1. A team approach to detail oriented problem solving.
2. A culture of communication and openness
3. A culture of self-education and improvement

1. Teamwork

As an example, note how many people are involved with making a prescription.
We very strongly push medical accuracy at this crucial step in the pharmaceutical process.

The doctor will talk to the client about potential side effects, what to look for, general expectations, and timeframe. He or she will WRITE the medication instructions on the in-take sheet, treatment sheet, or Rx form. Then it goes to the shift coordinator, who in turn reviews the information and delegates it to a 3rd team member, such as the discharge nurse.

The Center also follows a 3-point system for issuing pharmaceuticals:

If the client calls back later on with any questions, our front desk staff can check the patient’s file, the computer file, or have the doctor take the call if necessary. We communicate with clients on multiple levels, using multiple methods such as email, texting and voicemail.

2. A culture of communication and openness

We’re all human beings, and we all make mistakes – no matter what system you have, people can err. We have a “no fault” policy of reporting errors, although of course, steps are always taken to ensure that particular error doesn’t happen again. Along with this “no fault” reporting policy, I write up a report on any reported error, which goes in a file for future reference and consideration.

3. A culture of self-education and improvement

The Center is always encouraging our employees to grow in their knowledge basis. The better educated the staff member, the better we can prevent medical errors. And that confidence is key to making certain our staff speaks up. Every team member needs to be confident enough to ask, “Are you sure?” There’s no “How dare you question me?” attitude here. Our doctors are not above explaining themselves, or providing reasons for their decisions.

The Center gives every staff member a small annual budget for outside continuing education, for that staff member to use for CE courses as appropriate. We’re also in the process of developing formal internal training as well.

In general terms, you need to think about the kind of culture you’re creating. And you need to write it down. The written word is a very important piece of communication. Any time you write something down, you have an opportunity to double-check it.

The real prevention of medical mistakes involves seeing where a problem might occur, and preventing it in advance. It’s an “all hands on deck!” approach – everyone participates! The team at the Pet Emergency & Specialty Center of Marin continuously evolves to make the practice better and better.

Rounds, meetings, and eNewsletters

A little more on our approach to communication—we cover sentinel and adverse events at morbidity and mortality rounds, with the doctors and practice managers first so we can clarify how to address the staff and why. There are quarterly meetings as well, and the Center also produces an internal eNewsletter that’s circulated weekly. Last but not least, there’s always email, board postings, and individual (face-to-face) communication. There are different ways to communicate information, and we base the communication methods on the importance of the communiqué. It’s important for the distribution of policies, reviews, and medical discussions to remain flexible and appropriate to the situation.

But we consider every situation a team situation here at the Pet Emergency & Specialty Center of Marin. It’s one of our greatest strengths, and allows us to offer the best service possible to the community.
 

Many thanks to our 3 veterinary professionals for their in-depth discussions on how their clinics prevent medical errors!