Introduction

“First, do no harm” is a frequently cited tenet of the medical profession, often incorrectly attributed to the Hippocratic Oath (Shmerling 2015). It serves as a reminder that medical practitioners should, at all costs, avoid harming their patients. The reality, however, is that every individual devoted to the medical care of patients, whether human or animal, will occasionally make mistakes, and some of these mistakes will unfortunately harm our patients.

The original version of the Hippocratic Oath suggests that physicians should, “abstain from all intentional wrong-doing and harm.” By including the word “intentional,” this is a far more realistic goal, and one that all medical professionals should aspire to, while also accepting that we are imperfect and will occasionally make mistakes despite our best intentions.

A number of terms have been used to describe different types of conditions related to patient safety, which are summarized in Tables 9.1 and 9.2. Some published definitions for the same terms differ or even conflict.

The following example (Case Study 9.1) demonstrates different types of patient safety events.

As demonstrated by this example, there are many ways that patient safety can be compromised. It would be difficult to overstate the importance of medical errors given their potentially devastating impact on patients, family members, and healthcare team members. A study in the human medical field found that more than 250,000 patient deaths per year in US hospitals are attributable to medical errors, making medical errors the third leading cause of death in the United States (Mamary and Daniel 2016). The World Health Organization (WHO) estimates that 14% of hospitalized patients in higher income countries will experience an adverse event when hospitalized (Gartrell and White 2021). According to one source, 83% of physicians surveyed had experienced an adverse event or near miss at some point in their career (Harrison et al. 2014). In another study involving physicians in internal medicine, pediatrics, family medicine, and surgery, 92% reported being involved in a medical error or near miss (Waterman et al. 2007).

The veterinary profession is well behind the human medical profession in establishing systems to track, report, and productively address medical errors (Wallis et al. 2019). Reliable data on the actual incidence of medical errors in the veterinary profession are scarce. A survey of 606 veterinarians showed that 74% indicated being involved with at least one adverse event or near miss in the preceding 12 months (Kogan et al. 2018). In another study of 108 recent veterinary graduates in the UK, 78% admitted making a mistake since entering practice (Mellanby and Herrtage 2004).

In a study from three companion animal teaching/multi-specialty private practice hospitals using a voluntary reporting system, approximately five medical errors occurred per 1000 patient visits (Wallis et al. 2019). Forty-five percent of errors did not cause patient harm, however 15% resulted in severe harm. The frequency of serious errors causing permanent harm or death was less than 2% of reported incidents. Following an adverse event, however, more than 82% of patients had temporary harm. As these results were based on self-reporting, they almost certainly underestimate the true incidence and severity of errors.

In addition to causing harm to patients, medical errors are harmful to members of the medical staff. The emotional impact on healthcare team members in the human medical field has been investigated and described (Waterman et al. 2007; Harrison et al. 2015). In one study among US and UK physicians, approximately one-third reporting an adverse event or near miss indicated feeling that their work performance or personal life had suffered (Harrison et al. 2015).

Causes of Errors

The intent of identifying the causes of veterinary medical errors should be to seek better understanding, not to assign blame. Additionally, understanding causation is an essential step toward learning from our mistakes and making changes to reduce the likelihood of recurrent errors. Though often well intentioned, discussion of preventing medical errors is misguided, as it perpetuates the expectation that medical caregivers should be infallible. The terms error reduction or error mitigation are more accurate and appropriate. Some experts in the human medical field have argued that even the term “error” is antagonistic in a medical setting and perpetuates a culture of blame (Rodziewicz et al. 2021). Rather than focusing on individual failings, the trend in human healthcare has been to target improvements in delivery systems to reduce the probability of errors and mitigate their effects (Rodziewicz et al. 2021).

Extensive research has been performed in the human medical field seeking the causes of medical errors and attempting to classify them (World Alliance for Patient Safety 2005; Anderson and Abrahamson 2017; Clapper and Ching 2020). Broadly, errors may be due to individual factors and/or system/environmental factors. Individual cognitive deficits by healthcare team members may cause errors of commission (wrong action) or omission (failure to take action). Communication lapses, either due to miscommunication or a failure to communicate, are another broad category of errors.

Causation of medical errors is often multifactorial and is best understood by examining the entire system (Figure 9.1). Studies in human healthcare indicate that medical errors arise not only through individual acts of negligence or incompetence by practitioners but also as a result of system complexities (Kalra 2004). Both veterinary and human medical environments are complex, dynamic, and subject to cost and time constraints. Additionally, there is substantial variation in different healthcare facilities in the expertise of staff members, levels of staffing, equipment available, complexity of medical cases, quality of leadership, and organization size. When seeking to identify the causes of medical errors, it is essential to consider the broader context of the organization and to recognize that many errors have multiple root causes. Often errors in the system, rather than by sole individuals, are responsible for adverse events.

According to research of US human medical malpractice claims, the 10 most common errors were: (i) technical medical error; (ii) failure to use indicated tests; (iii) avoidable delay in treatment; (iv) failure to take precautions; (v) failure to act on test results; (vi) inadequate monitoring after a procedure; (vii) inadequate patient preparation before a procedure; (viii) inadequate follow-up after treatment; (ix) avoidable delay in diagnosis; and (x) improper medication dose or method of use (Clapper and Ching 2020).

Communication deficits have been identified as a common cause of errors in the human medical field. According to a 2007 report by The Joint Commission on Accreditation of Healthcare Organizations, communication failures were the leading cause of patient harm in healthcare (The Joint Commission 2007). The importance of communication failures as a cause of medical errors in human healthcare has recently been called into question. A systematic review of research articles related to medical errors did not support the assertion that a majority of errors are caused by miscommunication (Clapper and Ching 2020). Instead, errors of omission or commission were by far the most common, with communication errors causing just 10% of all errors. Accurate identification of the causes of errors is challenging, as many errors go unreported and reporting nomenclature and protocols vary widely.

Relatively few studies have been performed in the veterinary field investigating error occurrence or causation. In a three-year multi-center study conducted in the United States, drug errors were the most commonly reported (>54%) error type (Wallis et al. 2019). These errors were categorized as wrong patient, wrong drug, wrong route, wrong time, or wrong dose. Giving the wrong dose was the most common form (>40%) of medication error. Communication errors were the second most common (30%) error type. Communication errors were categorized as a failure of transmission (illegible handwriting, poor medium for transmitting information), a failure of the source (missing or incomplete information), or receiver failure (information forgotten or incorrectly interpreted). This study revealed that 39% of communication errors were transmission errors, 35% source errors, and 21% were receiver errors.

In two studies on veterinary errors, communication deficits caused or contributed to 30% of voluntarily reported errors at three US practices and 5% of coded insurance claim cases in the UK (Oxtoby et al. 2015; Wallis et al. 2019). An analysis of client complaints against New Zealand veterinarians revealed that communication between the veterinarian and client underpinned many of the regulatory notifications and complaints (Gordon et al. 2019).

Another study investigating causes and types of errors was based on claims made to the largest veterinary insurer in the UK (Oxtoby et al. 2015). Among 225 coded cases, causes included: cognitive limitation (51%), owner contribution (15%), lack of technical knowledge or skill (14%), productivity/time pressure (7%), failure of communication (5%), and other factors (individually <5%). As this study was based on insurance claims, an important limitation is that the findings regarding error types and causation may not reflect their actual distribution in practice. It’s likely that clients are more apt to pursue a claim with some types or causes of errors than others.

Cognitive error has been identified as the leading cause of human medical mistakes (Goh 2019) and was also the leading cause of errors identified in a veterinary study (Oxtoby et al. 2015). Cognitive error may be caused by excessive reliance on cognitive biases, the mental short cuts caregivers take to facilitate decision-making. In his text Thinking Fast and Slow, psychologist Daniel Kahneman reveals how prevalent these largely unconscious processes are in our everyday lives (Kahneman 2011). Two different types of thinking – System 1 and System 2 – have been described and are summarized in Table 9.3. Both types of thinking are essential for our daily function, expediting decision-making in some cases and slowing it in others (Kohn et al. 1999; Kahneman 2011).

Experienced medical caregivers tend to utilize System 1 thinking more often than less experienced colleagues. While this saves time and improves efficiency in practice, these shortcuts can sometimes lead to errors in thinking through medical cases. Diagnostic errors constitute a substantial portion of preventable medical mistakes, largely due to faulty clinical reasoning (Kohn et al. 1999). Often the culprit is excessive reliance on cognitive biases. Common biases in medical work include diagnosis momentum bias (failure to re-examine an existing diagnosis), availability bias (remembering a similar recent presentation), confirmation bias (overweighting evidence that supports an initial hypothesis), and search satisfying bias (stopping at the first plausible explanation) (Gartrell and White 2021). Effective clinical reasoning requires the intentional and courageous practice of rigorously examining assumptions and differing perspectives to inform better decisions and reduce the likelihood of medical errors.

Veterinarians and physicians often have demanding work schedules. A study of human medical interns showed elevated medical error rates among those sleeping less than six hours per night, working more than 70 hours per week, and who were acutely or chronically depressed (Kalmbach et al. 2017). Stress and fatigue have been documented to cause performance deficits and sleep deprivation has been identified as one of the main concerns in the practice of medicine. Stress has been recognized as a cause of errors affecting patient safety in veterinary practice (Oxtoby et al. 2015). Long, continuous working hours and sleep deprivation are incompatible with enhancing quality care and patient safety (Dinges et al. 1997; Shine 2002).

Another characteristic of medical practice is that caregivers are frequently interrupted as they go about their work, and these interruptions increase the risk of error. In a study of human nurses at two hospitals, the occurrence and frequency of interruptions were significantly associated with the incidence of procedural failures and clinical errors (Westbrook et al. 2010). In fact, each time a nurse was interrupted while preparing and administering medications resulted in a 12% increase in procedural failures and a 13% increase in clinical errors. Interruptions occurred in more than half of all medication administrations.

A subsequent study was performed to assess the effectiveness of a “do not interrupt” intervention with human nurses in Australia, which included donning a vest to indicate they were involved in an important task and should not be interrupted (Westbrook et al. 2017). Although a significant reduction in interruptions was achieved, nurses reported the intervention was cumbersome and less than half would support making this hospital policy. Interventions need to account for those interruptions that are necessary and integral to the medication administration process and target the reduction of interruptions that are unnecessary to the immediate safety critical task (Westbrook et al. 2017).

Yet another potential cause of errors in medical practice is the prevalence of power differentials among members of the healthcare team (Weller et al. 2014). Some doctors may distance themselves physically and/or figuratively from other members of the team performing nursing or client service tasks, creating communication barriers. By virtue of their position, and sometimes behavior, doctors are often viewed as having greater power than other members of the healthcare team. This power dynamic may reduce the likelihood of a nondoctor, or any less experienced member of a healthcare team, questioning directives, even when they sense a potential error.

Lack of adequate training or supervision undoubtedly also contributes to the occurrence of medical errors. In a survey of recent veterinary graduates, 82% said they “frequently or always” worked unsupervised (Mellanby and Herrtage 2004). Many veterinary practices are small businesses that lack formal onboarding procedures. Practices vary in the emphasis they place on ongoing training, and in what opportunities are available for members of the team.

Responding to Errors

When an error occurs, the initial focus is understandably and appropriately on efforts to mitigate harm to the patient and their family. Except in the case of fatal errors, immediate medical steps to care for affected patients should be a priority. Once the immediate patient care has been initiated, the following steps are often helpful:

1. If the owner is present and witnessed the event, you should immediately communicate with them.
   
2. If the owner isn’t immediately present, pause and take a deep breath. If you are directly involved in a serious error, it’s normal and understandable that emotions may arise that could make it difficult for you to function normally. If possible, discuss the situation with a colleague and ask for their support. This might include their taking over care of the patient so you can focus on other things and/or offering advice on how to proceed with the patient and client.
   
3. Unless you own the practice, it is advisable to immediately notify the owner and/or hospital administrator and seek their advice.
   
4. Make some quick notes. This is not the time for a detailed analysis: instead, capture the initial facts of the event, including the time frame and names of any individuals who were involved in any way, even as just witnesses to the event. When time permits (but relatively soon after the event) it is essential to record detailed notes in the patient medical record, including communications with the client.
   
5. It may be appropriate to contact your professional liability insurance carrier. Some agents have extensive experience with these situations and can offer helpful advice. Remember, however, that you need to feel comfortable with how the situation is handled.
   
6. As discussed throughout this text, it’s important to consider the ethical implications of the event to guide how you should respond.
   
7. Take a little time to review and mentally rehearse how you will communicate with the client.
   
8. Share the news with the client following the guidelines discussed in the section on “Communicating About Errors.” This should be a two-way conversation and include suggestions for a plan going forward.
   
9. For all sentinel events, complete a structured sentinel event investigation, which should include a root cause analysis.
   
10. Implement changes to reduce the risk of the event occurring again.

Choosing to disclose medical errors can be scary. A tension exists between the moral duty to acknowledge a mistake and the resulting harm vs. the desire to protect oneself from the potentially serious repercussions of admitting errors. There is growing encouragement and progress in the medical field, however, to develop compassionate and effective incident reporting systems (King et al. 2006). Reporting allows caregivers to honor their values and ethical beliefs, has the potential to rebuild trust and retain clients, and may reduce the likelihood of legal action or veterinary medical board complaints.

Unfortunately, studies in human and veterinary medicine indicate that there is widespread underreporting of near misses, adverse events, and errors. According to a study in the UK, “Research studies have validated an epidemic of grossly underreported preventable injuries due to medical management” (Barach and Small 2000). Another paper suggested that underreporting in the human field ranges from 50% to 90% (Oxtoby and Mossop 2019). According to another source, less than 10% of errors in the human medical field are reported (Anderson and Abrahamson 2017). Why is underreporting so prevalent in the human medical field? The 10 most frequently cited impeding factors were: professional repercussions, legal liability, blame, lack of confidentiality, negative patient/family reaction, humiliation, perfectionism, guilt, lack of anonymity, and absence of a supportive forum for disclosure (Kaldjian et al. 2006).

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