Significant event auditing part 2

In this case example, the total amount of methadone recorded in the controlled drugs register was more than the amount of stock. The requirement to reconcile controlled drugs is a legal and professional responsibility, so the practice identified this discrepancy as a significant event.

This case example will go into more detail about what happened and what the practice did as a result.

A significant event audit (SEA) is a quality improvement (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 decrease the likelihood of repeating outcomes that went badly.

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 the event is discussed without any blame – allowing team members to provide honest and constructive feedback on how they contributed to the care process.

An SEA is completed in six stages (VT49.29). RCVS Knowledge provides a free template, guide and course as part of its QI support for practices (www.rcvsknowledge.org/quality-improvement). The following case example will take you through the event and the steps this practice took to put their SEA into practice.

• The following mock case example has been written by members of RCVS Knowledge’s Case Example Working Party: Pam Mosedale, Laura Playforth and Angela Rayner.

It was the middle of morning surgery at the branch practice when Nicola was presented with a Labrador retriever with an acute abdomen.

Date of significant event: 21 February 2019

Date of meeting: 8 March 2019

Meeting lead: Julia

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

A high pain score was recorded and, after assessing major body systems, Nicola wanted to provide suitable pain relief immediately. She went to the controlled drugs cabinet and reached for the methadone bottle, only to find that one wasn’t open.

As she opened the new bottle, she flicked to the correct page of the controlled drugs register to see the running total was 17.5ml. She administered the methadone to the patient and admitted it for further diagnostics, then returned to sign the dose out of the register. A quick search through the cabinet didn’t reveal another bottle of methadone, so she left the running total blank and vowed to return to it later that morning.

The morning was busy and Nicola ended up taking the dog to surgery with a perforated linear foreign body. Luckily, afternoon appointments were quieter, so she returned to the register. A more thorough search still didn’t reveal another bottle of methadone.

She looked back to see where the weekly reconciliations had been done and was disappointed to find one hadn’t been conducted for the past four weeks. It seemed two had been missed due to annual leave and one she had forgotten to do herself. She spoke to the other vet, Julia, and their regular locum, David, and nobody could recall any missed doses.

Luckily, they could run a report on their practice management system (PMS) of when methadone had been charged and found two of the doses, but around 2.5ml still remained unaccounted for. Sadly, the trio had to spend some time one evening going through the hospitalisation records and, eventually, found a dose that had been missed from the register and not recorded on the PMS. Finally, the register balanced, although it looked rather disorganised.

SEA meeting findings

Julia and Nicola alternated accountability for the weekly checks on the register at the branch practice. Because this wasn’t written down anywhere, it was easily disrupted by a change in schedule, such as annual leave.

Julia and Nicola each thought the other had asked David to do the checks on two occasions, but it turned out neither of them had remembered to. As the checks weren’t done on a regular day, it was very easy to forget.

Both vets felt the shared responsibility had meant they were lulled into a false sense of security, and had both become more relaxed about recording in the register at the time the doses were given, which led to a couple of missed entries.

On a couple of occasions, all the vets admitted to leaving the key in the cabinet door when it was busy for ease of access, which had heightened their concern that someone else could have accessed the cabinet – they had recently had an open day and couldn’t recall with clarity exactly where the key was at that time.

Why did it happen?

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

System factors

• No one person was accountable for the controlled drugs process.
• A lack of defined process for the weekly reconciliation had led to omissions being missed for a period of time.

Human factors

• The team was busy dealing with multiple patients at once.
• Julia was feeling stressed and very much looked forward to her holiday, so didn’t take the time to double check the register before she went on leave, or ensure processes were in place for checking while she was off.

Patient factors

• None.

Owner factors

• None.

Communication factors

• Lack of clarity of communication led to neither permanent vet alerting the locum to what was expected of him in terms of reconciliation.

Other

• A culture of being less rigorous with register entries had developed.
• It turned out the student VN had noticed the key being left in the cabinet on two occasions, but didn’t want to speak up for fear of being seen as critical of the vets.

What has been learned?

The whole team was very relieved it found the missing doses and reconciled the register. The team realised had it been unable to do so, it may have had to inform the police and it may have been discovered by Practice Standards Scheme assessors at their upcoming visit. It may also have become more widely known the practices had fallen short of ensuring safe custody of the controlled drugs at all times.

The team learned that by taking a more systematic approach, rather than relying on the assumption that each member of the team knew what he or she needed to do, meant that it could avoid this happening again.

The team was saddened to feel its safety culture in this area had slipped – team members recognised the importance of fulfilling their legal and professional obligations, and also safeguarding the well-being of colleagues and the public.

The vets involved felt disappointed their attitude had made the student VN feel like she couldn’t speak up. They reassured her that her views on all processes and practices within the clinic were welcomed.

What has been changed?

CPD/training required

• The vets refreshed themselves on their legal responsibilities in this area.

New or updated protocols/checklists/guidelines

• A protocol for increased reconciliation and audit was implemented.
• It was decided Julia would have overall responsibility for the controlled drugs process and register, and it was her responsibility to delegate it when she wasn’t there. Although Julia is not the clinical director (CD) of the practice, the CD rarely worked at the branch and has many other responsibilities. When asked, Julia was keen to take this responsibility on herself.
• All team members agreed to write doses in the register immediately after administration (as long as animal welfare wasn’t compromised).

Further audit required?

• The team decided to increase the reconciliation of all controlled drugs against the register twice-weekly, and then undertook a process audit monthly to ensure the twice-weekly checks were being performed accurately.
• The team also reconciled the register against the usage report from the PMS, as well as the amount of drugs present.

Other

• None.

Follow-up date

A follow-up date of 8 April 2019 was decided.

RCVS Knowledge has teamed up with members of the profession to develop free resources for significant event audits – especially for practice-based veterinary teams. The resources include:

• a free 20-minute online CPD course
• a 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
• handy tools to help you identify the root cause of the event

RCVS Knowledge has similar resources for practices looking to complete clinical audits, or develop checklists and guidelines. For more information, visit https://bit.ly/33Qx2b2

The QI Vets case examples are published on a regular basis. You can find previous editions online at https://bit.ly/2p4VQ0g  and http://bit.ly/QIVets