1 Mar 2021
RCVS Knowledge, the charity advancing the quality of veterinary care, describes a quality improvement case example concerning an overdose of premedication in a canine patient.
RCVS Knowledge
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The next QI Vets significant event audit (SEA) case example details what the practice did after a patient received an overdose of its premedication due to a calculation error.
QI Vets is a fictional team based on true stories from UK practices. Created by RCVS Knowledge’s Case Example Working Party, this series of cases has been designed to help veterinary teams apply quality improvement (QI) to real situations.
An SEA is a QI technique. It is a retrospective audit that looks at one case in detail from beginning to end, to either increase the likelihood of repeating outcomes that went well or to decrease the likelihood of repeating outcomes that went badly. An SEA is completed in six stages.
SEAs may guide further development of guidelines, protocols or checklists and may result in the need for additional clinical audits to measure whether the changes have been adopted (process audits), or whether the change led to an improvement (by auditing either structural changes or outcomes).
SEAs are conducted by bringing your team, and the relevant case notes, together to discuss the event. It is important that the event is discussed without any blame to allow team members to provide honest and constructive feedback on how they contributed to the care process.
RCVS Knowledge provides a free SEA template, guide and course as part of the charity’s QI support for practices. Visit www.rcvsknowledge.org/quality-improvement
The example in the panel to your left will take you through the significant event and the steps the practice took to establish what went wrong, and what processes would decrease the likelihood of it happening again.
RCVS Knowledge has teamed up with members of the profession to develop free resources for SEAs – especially for practice-based veterinary teams.
The resources include:
RCVS Knowledge has similar resources for practices looking to complete clinical audits or develop checklists and guidelines. For more information, visit www.rcvsknowledge.org/quality-improvement
The QI Vets case examples are published on a regular basis. You can find previous editions online at www.vettimes.co.uk/articles/rcvs-knowledge and rcvsknowledge.org/QI-Vets
Practice: QI Vets
Date of significant event: 20 August 2020
Date of meeting: 22 August 2020
Meeting lead: Miguel
Team members present:the whole practice team – vets, RVNs, animal care assistants and receptionists
It was Miguel’s first day back after being on furlough for the past few months. He had a full morning of consults and was needed at the branch later that afternoon to help with another procedure.
Miguel’s favourite lurcher, Grace, had been booked in that morning for a dental as requested by her owner, Dr Caine. While it was his only procedure, several extractions were expected.
Lucy was working that morning and knew she had to help with Miguel’s procedures to be able to get him out to branch on time. She also had time constraints, as she had to help with a busy afternoon of car park consults in the rain. As soon as Grace was dropped off by her owner, she started whining and barking, so they were keen to get her home as soon as possible.
Miguel wrote down the premedication dosages for medetomidine and methadone, and went to finish his final consult. Lucy prepared for the dental and administered the premed. When Miguel returned, Grace was found in her kennel profoundly sedated and bradycardic. It was then discovered that the volume of medetomidine that was written down was 1ml when it should have been 0.1ml.
As soon as the error was discovered, the medetomidine was reversed and IV fluids administered. Grace made a full recovery and her dental was delayed for another day. The reason for the delay was explained to Dr Caine, who was grateful that the error had been found and that Grace seemed unfazed by the events of the day.
Miguel and Lucy felt under pressure to get the dental under way as quickly as possible, given the time pressures of the day and the length of the procedure. They both felt it was difficult to focus, Miguel was feeling overwhelmed and Grace’s whining was shaking the walls of the practice.
The team discussed and recorded the factors that had led to this event as follows:
On reviewing the incident with the team, it was found that others had experienced similar events, but had realised the error before giving the drug (near miss). It was felt that having a dose chart by patient weight would help to prevent dose calculation errors and would help the nurse to sense check any dose that was written down. It was also felt that double-checking the dose with the vet – for example, saying “you want me to give ‘x’ ml of medetomidine” – and the vet verbally confirming the dose may provide another sense check (closed loop communication).
Adam said that at times he has trouble reading the vets’ writing, while all the nurses nodded their heads in agreement, and he was concerned as this had led to a near miss in his experience. Harriet shared that in her nursing course they were taught to ensure that a digit is written down on either side of the decimal point.
For example:
They all agreed that this was a much clearer system.
Overall, the team felt that Miguel and Lucy handled the error well. They communicated the error honestly to the owner and had Grace’s safety as their primary concern.
As many of the practice team had previously experienced similar near misses, it was felt that sharing them could have prevented this error from occurring. It was decided that near misses would be included in significant event reviews so that measures could be put into place before harm comes to patients.
l No official training was required. However, discussion of the learnings with the team took place.
New or updated protocols/checklists/guidelines
A follow-up date of 20 December 2020 was decided.
