Significant event auditing part 5

QI Vets significant event audit (SEA) is back, with the team assessing what systems were in place after a patient was admitted for treatment of meloxicam overdose.

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. 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 SEA template, guide and course as part of the charity’s QI support for practices. Visit www.rcvsknowledge.org/quality-improvement

Further information

RCVS Knowledge has teamed up with members of the profession to develop free resources for SEAs – 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 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

Dash the dachshund underwent routine neutering and the veterinary surgeon, Nicola, prescribed a short course of oral meloxicam for postoperative pain relief.

The surgical nurse, Adam, dispensed the medication and placed it on Dash’s kennel so it would be sent home with him.

When Mr Campbell arrived to collect Dash, the nurses were busy with patients and the veterinary surgeon was in afternoon consults, so Dash was discharged to Mr Campbell by Andrew, the receptionist, who handed over the medication, booked a recheck appointment and took payment.

Mr Campbell brought Dash back a few days later for his postoperative check and reported that Dash had bloody diarrhoea. During the consultation, it was discovered that Mr Campbell had been administering a 45kg dose of meloxicam, instead of the prescribed 4.5kg dose.

Dash was hospitalised, and treated successfully with IV fluids and supportive care. Mr Campbell stated that he thought the amount he was giving him “seemed like a lot for Dash” and that “he’d better go get his eyes checked” as the 4.5 on the label looked like 45 to him.

SEA meeting findings

Andrew blamed himself for Mr Campbell’s confusion. It had been a busy afternoon with several clients waiting at reception and he felt rushed off his feet.

He stated that he “usually goes over the medication with the client, but felt he couldn’t due to time pressures”.

The nurses felt bad as they thought they should have found a way to help Andrew with the discharge appointment.

When checking the dispensed medication it was found that:

• the instructions on the prescription label were correct
• both the small and large syringes were left in the box
• the summary of product characteristics (SPC) was included in the box

Why did it happen?

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

System factors

• No dispensing protocol was available.
• No double-checking system of medicines in place.
• Both small and large syringes were in the box.

Human factors

• Staff unable to focus on tasks due to a busy day.
• Help was unavailable as staff were tied up with other tasks.

Patient factors

• None.

Owner factors

• Owner misread instructions.

Communication factors

• Medications were not reviewed with the owner.
• Owner did not communicate with the practice when unsure about the dose.

Other

• None.

What has been learned?

Andrew initially put the blame on himself, but was relieved when, during the team meeting, he realised that several factors had contributed to the event. No one was to blame, it was that no system was in place that could have reduced the likelihood of this event occurring.

It was generally felt by all staff that a dispensing protocol would be the appropriate solution, and input was given by everyone involved. The necessity of encouraging owners to ask questions was also realised, and the team discussed several ways to facilitate this.

The staff felt good that they had all pulled together to care for Dash. He was doing well and Mr Campbell was happy with the outcome.

What has been changed?

CPD/training required

• Training and communication to be given on the new dispensing protocol and audit.

New or updated protocols/checklists/guidelines

• A dispensing protocol was developed and included the following procedures for meloxicam:
• When the vet prescribes meloxicam, numbers will be followed by the written numbers in brackets – for example, 45 (forty five).
• When dispensing the medication, the nurse will double check that the dose corresponds with the weight of the patient and remove the inappropriate syringe.
• The appropriate syringe will again be checked by the person who hands over the medication.
• The dose to be given will be demonstrated to the owner, with a mark (white tape) put on the syringe at the appropriate level.

Further audit required?

• An audit of meloxicam waiting to be collected, to include the following:
  • Dose is not more than the weight of the patient.
  • The inappropriate syringe has been removed.
  • The appropriate syringe has been marked at dose level. SPC is contained in the box.

Other

• None

Follow-up date

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