We are all in this profession for one primary goal – to improve animal welfare. But this can only be achieved by improving our own approaches, and constantly striving for expert performance.

There is a well-known saying, popularised by Malcolm Gladwell in Outliers, that to truly become an expert in a particular field, we need roughly 10,000 hours of purposeful practice.

Purposeful practice requires high standards and even higher-quality feedback. At the core of high-quality feedback is mistakes.

Mistakes are an inevitable truth of life, especially in areas focused on high performance. We are all human, and no human is infallible, so it is incredibly unfortunate such a stigma around the art of making mistakes in veterinary medicine and other health care professions exists.

Mistakes are so crucial to learning that they can be considered the paradox of expert performance – mistakes are needed to truly maximise potential.

Quality improvement focuses on taking these mistakes and analysing them with various methodologies, such as root-cause analysis, crucially allowing us to learn from them. I am delighted to have been given the opportunity to write about such an incredibly important topic, and wanted to touch on why I believe our highly skilled, highly competent veterinary nurses can be integral to quality improvement.

Preparation is key

I am honoured to work alongside a fantastic team of forward-thinking registered and student veterinary nurses. Without the team of RVNs taking control in our prep room, our surgical efficiency would be greatly reduced.

Using a few examples, I wanted to briefly touch on how RVNs are crucial to day-to-day running in general practice, and how embracing quality improvement, such as by introducing surgical and anaesthetic checklists, can help improve the standard of care we give to all our patients.

All about anaesthesia

I recently attended a fantastic talk at BSAVA Congress delving into management of intra-operative hypotension.

One of the biggest take-home messages from said lecture was almost every drug we are giving in anaesthetic protocols is pharmacologically designed in some way to kill our patients. Obviously, the aim is to prevent this from happening, but all of the common drugs have undesired side effects if given in the wrong way, at the wrong dose, in the wrong combination or to the wrong patients.

For this very reason, it is imperative precautions are put in place to safely perform anaesthesia. Fortunately, many of the drugs we use do have in-built pharmacological safety measures – in the form of half-lives and reversal agents – but we will come to that later.

For the majority of general practices out there, RVNs will be responsible for the maintenance of safe anaesthesia. Seemingly simple interventions, such as the anaesthesia circuit checklist popularised by the Association of Veterinary Anaesthetists, can have profound effects on patient outcome.

As alluded to earlier, deliberate practice of these interventions can lead to expertise – but to the RVNs out there, you are already well on your way to doing this. By championing anaesthetic safety checklists, you can help prevent issues before they arise. Prevention is better than reactivity, and deliberate practice in the use of anaesthetic checklists can help keep our patients safe.

But what if things don’t go to plan? Inherently, checklists are also fallible, depending on how they are implemented. If we use checklists as tick-box exercises, without truly thinking about each step and why they are important, mistakes are still likely to happen.

People often worry about the punitive repercussions of making a mistake; they worry that by admitting fault, they will be reprimanded for doing so. At this point, I would like to repeat the first sentence of this article: we are all in this profession for one primary goal – to improve animal welfare.

“We are all in this profession for one primary goal – to improve animal welfare”

If you knowingly make a mistake, and do not act on it, you are having a direct adverse effect on animal welfare. Mistakes happen, but trying to cover them up or give excuses doesn’t help the animal. If I were being anaesthetised, and the anaesthetist had accidentally given me an overdose of a drug, I would much rather they were open about the mistake so people could get to work on fixing the error.

Let’s use a simple example of pre-medication with methadone. Imagine a nationwide shortage of your regular methadone-containing product exists and a replacement has been ordered in without everyone being notified. During a busy morning, the nurse responsible for working out the drug volume inadvertently recalls the wrong concentration of the methadone as 2mg/ml instead of 10mg/ml.

As it is so busy, the usual process of having another person check the drug dose is glossed over, and the demanding veterinary surgeon has asked for a dog to be premedicated immediately. The dog receives five times the intended dose and becomes markedly more depressed than intended in the kennel.

The veterinary nurse who premedicated the animal notices the dog appears unwell and goes to the anaesthetic sheet, checking the volume of drug that was given and then checks the methadone-containing product bottle. He or she notices the new product actually contains 10mg/ml, and this has led to an overdose.

In these situations, it is important to think about what the worst outcome could be: perhaps this dog could theoretically crash from overdose? (I appreciate this may be unlikely, but just want to illustrate a point). What do you do? Do you:

• a) Alter the sheet so no one notices the error?
• b) Ignore the issue and hope everything is okay?
• c) Alert the team to the issue?

Maybe the patient will be fine, regardless of what you choose. However, what if you pick option a) or b) and the patient dies under anaesthetic? Yes, if you pick option c) you may feel embarrassed about the error, or be worried that you will be reprimanded in one way or another, but what about the patient?

It is my hope everyone reading this article would shoot for option c). Even if you don’t stock naloxone at the practice, alerting the team to the issue allows for further, closer monitoring of the patient, enables someone to source naloxone (from a local hospital/pharmacy with prescription) or give the patient butorphanol as a “next best” option.

It is our moral duty to identify when these errors happen and act on them. The reality is making a mistake like the one aforementioned is not negligence if you choose option c), but it could become so if you choose option a) or b). So, what next? Let’s carry on the example.

The dog has received naloxone, the owner is informed, and the procedure is postponed for a few days. The owner appreciates the mistake has happened and been dealt with, but wants to know why it has happened and what is being done to stop it happening in the future.

How can we continue this opportunity for learning and help prevent further incidences of similar mistakes?

“I believe our highly skilled, highly competent veterinary nurses can be integral to quality improvement.”

We have all made mistakes like the one aforementioned – simple mathematical errors that occur when we are distracted by other issues.

This is where you can be a practice champion of quality improvement. The best way to learn from an error is to think about how the error has come about and analyse it during a formal significant event audit with the practice team. Several contributing factors exist to the aforementioned scenario, so it is important to highlight them without attributing blame, but accepting responsibility for the issue.

Having a practice meeting about the issue may identify several steps that led to the dog being overdosed; a non-exhaustive list includes:

• A lack of practice awareness of differences in concentrations of replacement stock.
• The packaging was not inspected prior to drawing up the drug.
• The “working out” of the total drug volume was not checked thoroughly.
• Due to the “busy morning”, the usual process of checking the right drug, right concentration, right route and right patient was ignored.

These four points could be discussed among the team, and the following changes implemented as a result. I would like to stress these aren’t necessarily definitive, nor will they be appropriate for all individual practice teams, but hopefully you will be able to use this information as a starting point for your own discussions:

• All replacement stock should be identified and checked for discrepancies in concentrations, and people who are responsible for using said drugs notified of any changes.
• All drugs will be placed back in their original packaging in-between each patient.
• All anaesthetic drugs will be worked out with mg/kg dose rate, total mg, mg/ml concentration and total volume to be administered (ml).
• No drug will be given without being signed by at least two separate members of staff, including the person responsible for deciding the dose in mg/kg.

The outcome of the aforementioned situation is then monitored for recurrence, and at the next regular practice meeting, the implemented changes are discussed for efficacy. Fantastic.

Due to the multifaceted role and skillset of RVNs, they are in an excellent position to champion the aforementioned process. By becoming the quality improvement officer for a practice, an RVN can help identify areas of concern and collaborate with the entire team to produce guidelines for improvement.

A job well done

Not only are our RVNs directly exposed to potential situations as per the aforementioned on a regular basis, the critical skills that develop during routine anaesthesia are fantastic for applying quality improvement in a practice. Anaesthesia trains you to notice changes and trends, and our RVN anaesthesia teams are constantly exposed to rapid feedback from patient vital parameters.

One last time: we are all in this profession for one primary goal – to improve animal welfare.

I urge you to think about the situations where mistakes could happen, or have happened, and the major role our RVN teams can play in identifying, managing and preventing adverse events in day-to-day practice.

RCVS Knowledge provides a range of resources – significant event audits, checklists, guidelines, courses and more – to help you put these into practice (https://bit.ly/2EnM0Lt).

Please take time to read through some of them, as the wonderful team has identified common errors that can help you make beneficial changes in practice.