Significant event audit: incorrect saline type

The next QI Vets significant event audit (SEA) case example details what the practice did after a patient received hypertonic saline instead of isotonic saline, which contributed to the loss of the patient.

QI Vets is a fictional team, but based on true stories from UK practices, created by RCVS Knowledge’s Case Example Working Party 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 result in 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 (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 – allowing team members to provide honest and constructive feedback on how they contributed to the care process.

RCVS Knowledge provides a free significant event audit template, guide and course as part of the charity’s QI support for practices at www.rcvsknowledge.org/quality-improvement

The case example presented in the panel below will take you through the event and the steps this veterinary practice took to establish what went wrong and what processes would decrease the likelihood of it happening again.

Further information

RCVS Knowledge has teamed up with members of the profession to develop some free resources for SEAs – especially for practice-based veterinary teams.

The resources include:

• a free 20-minute online CPD course
• a quick guide to take you through the steps of what you need to do when conducting an SEA
• a template so you can record the incident and the audit
• other significant event case examples such as this one
• some handy tools to help you identify the root cause of the event

RCVS Knowledge has similar resources for practices to complete clinical audits and to create 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 http://bit.ly/QIVets

Case example

Date of significant event: 2 August 2020

Date of meeting: 6 August 2020

Meeting lead: Julia

Team members present:the whole practice team – vets, RVNs, animal care assistants and receptionists

Ms Anand brought her cat, Ryan, to see her usual vet out-of-hours, as he had been straining to pass urine and seemed in a lot of discomfort. The veterinary surgeon, Julia, diagnosed a blocked urethra, and began diagnostic workup and preparing for IV fluid administration.

At the same time a dog was rushed in that had been involved in a road traffic collision (RTC) and two additional clients were waiting to be seen. The RTC dog was triaged, and Julia and the nurse, Clare, started IV fluids with an analgesia constant rate infusion (CRI), as the dog had multiple fractures and was in a lot of pain.

In the midst of this process, Ryan’s IV fluids were started, along with his analgesia, and the team moved on to see the remaining clients while continuing the monitoring of the inpatients. The RTC dog developed a pneumothorax and the team was focused on addressing this – when team members came to check the inpatients again they found Ryan having seizures.

The seizures stopped rapidly and the team was able to draw blood to assess electrolytes – this is when severe hypernatraemia was diagnosed. On reviewing the IV fluids the team realised a bag of hypertonic saline had been administered in error.
Tragically, despite rapid and appropriate therapy, Ryan could not be saved. Julia telephoned Ms Anand with the tragic news.

SEA meeting findings

Julia was very stressed about having multiple serious patients to attend to at the one time, in addition to one of the waiting clients being vocal about their discontent. She was intently focused on calculating the CRI for the RTC dog as this is not a process she performs often and she was worried about making a calculation error.

She was aware of taking a number of different fluid bags out of the cupboard to decide which fluids to put the RTC dog on, but could not recall getting the fluids ready for Ryan the cat. The nurse assisting her could not recall getting the fluids ready for Ryan either; it was unclear who had prepared the bag and attached it.

It was clear no discussion or final check of the fluids had occurred before administration began as a lot was going on at once and both clinical team members were distracted by other patients’ needs.

The cupboard where the fluids were kept had become disorganised after multiple team members had searched through bags to find what they needed. Clare was not aware that hypertonic saline was something the clinic kept and she had not seen it used before.
The receptionist, Andrew, who is very good at setting client expectations on wait times, was away from his desk scanning some paperwork in the office.

Why did it happen?

The team discussed and recorded the factors that had led to this event as follows:

System factors

• Storage of fluids had become confusing.
• No separation of “high-risk” fluids.
• No verbal confirmation or double-checking of fluid type or rate.
• Not all of the team was aware of which fluids were stocked and the potential risks.
• The scanner was situated away from the reception desk, so Andrew was unable to mitigate the impact of the unhappy client in the waiting room.

Human factors

• The team was busy dealing with multiple patients at once.
• Julia was focused on a complex CRI calculation, and an unusual and complex procedure.
• The team was distracted by the unhappy client in the waiting room.

Patient factors

• Ryan already had fluid and electrolyte imbalances from his pre-existing condition and was not a well individual to begin with.

Owner factors

• Ms Anand works long hours and had not seen Ryan for some time, so he was very ill when admitted.

Communication factors

• Lack of communication about the fluids.
• The communication around the treatment plans for all patients could have been improved with hindsight. Julia was stressed and stopped talking things through with Clare as she usually would have.

Other

• Practice culture that sorting out the fluid cupboard was “someone else’s job”.

What has been learned?

The whole team was very upset by the incident and the tragic outcome. The team members discussed how they felt in a brief and all agreed that they must change processes to minimise the chances of this ever happening again.

Agreeing the changes made them all feel that at least something positive could be changed for the future.

Julia felt that having some additional clinical guidelines and a CRI calculator to hand would have made her less distracted and more comfortable with multiple patients.

At a later meeting, the team also discussed what went well during the incident – the team was honest with Ms Anand who, although very upset, was very understanding of the incident and how upset everyone was. She appreciated how candid the team was and that she was informed of process changes for the future.

The team also discussed that Ryan’s care, once the error was identified, was immediate, high quality and well-coordinated.

What has been changed?

CPD/training required

• No official training was required. However, discussion of the learnings with the team took place.

New or updated protocols/
checklists/guidelines

• A protocol for verbally confirming fluid type and rate was developed by the team.
• A CRI calculator was sourced and placed on the practice computers for ease of access.
• A guideline for treating a pneumothorax was drafted by the team.
• A triage/immediate treatment sheet was reviewed by the team and introduced.

Further audit required?

• Process audit of whether the team was using the fluid protocol it had developed.
• The team decided to audit the triage sheet at a later date.

Other

• The hypertonic saline was wrapped in red conforming bandage as soon as it was delivered, before it was placed in stock. It was kept in a separate cupboard from the other fluids.
• All team members were made aware of which fluids were kept in stock.
• A list of “high-risk” fluids and medications was drawn up, with special precautions decided for each one and all team members made aware.
• Organising the fluid cupboard was assigned via a shift duty rota and the team chose baskets for each type of fluid.
• A hand-held scanner was purchased for reception so Andrew and the other receptionists could be in reception more

Follow-up date

A follow-up date of 6 October 2020 was decided.