Significant event auditing part 3

The first QI Vets significant event audit (SEA) case example of 2020 details what the practice did after an equine patient requiring some local anaesthetic received a dose of sedation instead.

The following example 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.

An SEA is a quality improvement 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.

An SEA is completed in six stages (VT49.29). SEAs may guide further development of guidelines, protocols or checklists and may result in the need for additional clinical audits (process audits) to measure whether the changes have been adopted, or whether the changes 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 the event is discussed without any blame; allow 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 quality improvement support for practices.

Visit www.rcvsknowledge.org/quality-improvement

Case example

Date of significant event: 2 December 2019

Date of meeting: 9 December 2019

Meeting lead: Stefan

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

Stefan had a call to visit Mrs Bartlett, an equine client, first thing in the morning. It was a client he knew well, so he was looking forward to a good cup of tea and a natter.

Neuf was a sport horse that had recently suffered from left forelimb lameness, affecting his ability to jump. Stefan loaded up his car with the kit he needed for a lameness workup, including mepivacaine for nerve blocks.

The palmar digital nerve block was negative, so an abaxial sesamoid nerve block was performed. This was also negative, but after 10 to 15 minutes, Neuf was starting to look sedated.

It was noticed that instead of using mepivacaine, Stefan had injected detomidine. Stefan apologised for the mistake and the lameness workup was postponed until the sedation wore off. Stefan was still offered a cup of tea while he waited to ensure that Neuf was going to recover without complication.

SEA meeting findings

The bottles for mepivacaine and detomidine were similar in appearance, and kept in the same place in the visit box. Stefan had picked up the detomidine, believing it was mepivacaine. Mrs Bartlett was very understanding of the mistake; however, she wanted to make sure it did not happen again.

Why did it happen?

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

System factors

• No system was in place to keep different drugs separated.
• The bottles were very similar in appearance.

Human factors

• The name of the drug was not double-checked before administration.
• Stefan was not focused on differentiating between the two bottles.

Patient factors

• None.

Owner factors

• None.

Communication factors

• None.

Other

• None.

What has been learned?

On reviewing the event with the team, it was found that Stefan had picked up the wrong bottle and, instead of using mepivacaine, used detomidine by mistake.

The two bottles, both 10ml in size, looked similar and were kept in the same visit box. The total injected SC was approximately 5ml, which was enough to cause sedation.

Thankfully, Neuf did not suffer any long-term effects and the client was understanding, but detomidine is an expensive drug, so it was a costly mistake.

The team had found that keeping drugs of similar appearance in separate places within the practice had helped to prevent comparable events in the past.

It was felt that keeping sedative drugs in a smaller, separate container within the visit box would help minimise confusion over these drugs in the future.

The importance of taking a moment to double‑check the drug before administering it was also discussed.

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 new protocol was developed for the storage of certain drugs within the visit box.
• The protocol on the storage of drugs with a similar appearance in practice was reiterated to all team members.

Further audit required?

• An audit of the visit box was completed to ensure drugs were being separated as per the new protocol.

Other

• None.

Follow-up date

A follow-up date of 9 January 2020 was decided.

• Written by members of RCVS Knowledge’s Case Example Working Party: Pam Mosedale, Laura Playforth and Angela Rayner.

Further information

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 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