The second QI Vets significant event audit (SEA) case example of 2020 details what the practice did after a near miss in the dispensary, where a feline patient requiring enrofloxacin tablets received 150mg, not 15mg.

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.

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 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 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. The event must be 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 SEA template, guide and course as part of the charity’s QI support for practices. Visit https://knowledge.rcvs.org.uk/quality-improvement

Case example

Mr Smith, who is 82 but very fit apart from arthritis, brought his old cat Fred into the surgery with an abscess following a cat bite. He saw a locum vet, David, who prescribed enrofloxacin tablets.

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

A new SVN, Harriet, who started at the practice that week, put up the tablets according to the instructions on the label. Mr Smith got to reception and told the receptionist that he did not think that he could give tablets to Fred.

The eagle-eyed receptionist, Andrew, who had been at the practice for 20 years, noticed they were 150mg tablets instead of 15mg. He went to see the vet, who asked Mr Smith and Fred to come back in. The vet gave a long-acting antibiotic injection and arranged to see Fred again in 48 hours. Andrew recorded this incident in the “near miss” book in the dispensary.

SEA meeting findings

David was busy that morning, his appointments were double-booked and he was in a bad mood – his car had broken down on the way to work and he was worried about the repair cost. He had left his glasses in the car, but luckily had his spare reading glasses with him.

Harriet had not had any formal induction as the head nurse was off sick. She had not worked in the dispensary before, but the practice was very short‑staffed that day.

She had never worked with David before, and she had questioned a couple of things earlier in the day, but he had been very short with her. She wasn’t sure that the tablets were correct, but was reluctant to say anything.

Andrew said that Mr Smith had told him, at reception, that he had no chance of getting the tablets down Fred. When Andrew looked at the tablets, he immediately saw they had a dog picture on as they were in a clear plastic bag.

Andrew went through and told David, who was very embarrassed and upset that he had clicked on the wrong drop-down box.

Why did it happen?

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

System factors

• No induction for Harriet.
• No dispensary training for Harriet.
• No clear dispensing protocols.
• No double-checking of tablets by a second person.
• Antibiotic prescribing policy not shared with locum team members.

Human factors

• The team was busy, understaffed and rushed.
• David was distracted by external matters.
• The team had not worked together before or regularly enough.

Patient factors

• None.

Owner factors

• Mr Smith had not told David in the consultation that he could not give Fred tablets.

Communication factors

• Lack of communication between Mr Smith and David.
• David had not asked whether Fred would take the tablets.
• Poor communication between colleagues – especially David and Harriet.

Other

• Practice culture – the junior nurses often feel they cannot question the status quo.
• Locums are not included in practice discussions and resulting policies not shared with them.

What has been learned?

David was very embarrassed by the whole incident. In the discussion, other vets admitted they had also found the drop-down boxes fiddly and it had nearly happened to them. He felt better after the discussion.

David apologised to Harriet and said he always valued nurses’ opinions, but was distracted that day. The practice manager agreed to review the appointment schedule once she had information from the client waiting times audit, in view of overbooking at busy times.

The whole team congratulated Andrew on spotting the error and pointing it out politely to David so it could be rectified and no harm was caused. The valuable role of reception in being the last check with medicines was highlighted to the whole team.

What has been changed?

CPD/training required

• Team training on dispensing protocol.
• Better inductions/shadowing for all team members.
• Team members not to be put in situations they are not trained for.
• Senior nurse put in charge of dispensary and to organise team training.
• Communication training for the whole team.
• Training in the responsible use of antimicrobials.

New or updated protocols/checklists/guidelines

• New protocol on dispensing.
• Introduction of double initialling system for dispensed medications.
• Updated PROTECT poster¹ after team meeting with all vets, including locums.

Further audit required?

• Process audit of how the team was complying with dispensing protocol.
• Audit of double initialling medications.
• Audit of client waiting times.

Other

• Contact database provider to query making the drop-down boxes bigger/clearer.
• Improve practice culture so that everyone’s voice is listened to equally.
• Sizes of packs of medicines highlighted and different sizes clearly separated. While not the cause of the error on this occasion, could be an issue if the correct box was ticked, but wrong medicine chosen.

Follow-up date

A follow-up date of 8 April 2020 was decided.

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 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://knowledge.rcvs.org.uk/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