Significant event auditing part 6

QI Vets is back with another significant event audit (SEA) in practice.

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.

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

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.

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.

An SEA is completed in six stages. RCVS Knowledge provides a free template, guide and course as part of the charity’s QI support for practices at www.rcvsknowledge.org/quality-improvement

The case example presented below will take you through the event and the steps this veterinary practice took to put their SEA into practice.

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

Case example

Beth works in mixed practice doing mostly small animal work with some farm calls, where she has backup from two dedicated farm vets. One weekend, she is on rota for farm animal emergencies when she is called out to a dairy farm for a case of suspected mastitis.

On arrival at the farm, Mr Firth, sensing an opportunity with an unfamiliar face, immediately requests an antibiotic with zero milk withhold. Beth informs Mr Firth that the first course of action is to get a milk sample for culture and sensitivity before using any critically important antibiotics.

The practice protocol of obtaining a sample, starting a course of broad-spectrum antibiotics and NSAIDs as necessary, and rechecking regularly is explained. Mr Firth guides Beth towards the crush where “258” is waiting and a clinical exam is started.

Beth confirms mastitis in the back left quarter and starts to collect a sample by using a liberal amount of surgical spirit, cotton wool and determination to avoid the sh**tty end of 258’s tail!

While retrieving the sample, Beth frantically thinks of what suitable antibiotics she has in the visit box. Deciding on a “back to basics” approach, she chooses penicillin/streptomycin and, after googling the dose rate, injects 1ml/25kg intramuscularly, to be repeated once daily for three days.

During the examination Mr Firth continuously engages in conversation about his son and ongoing tractor repairs taking place on the farm.

Once the exam is over Beth reminds Mr Firth that the milk withhold must be adhered to for the antibiotics. Mr Firth waves away her concerns about writing it down, as he says that he has a system of writing on the whiteboard for the relief milker.

Mr Firth had also recently treated a cow with mastitis with the same medication. Beth, relieved to hear that another colleague had recommended the same treatment, returns to the practice to continue with her small animal inpatients.

A few weeks later another colleague returns from a visit to Mr Firth’s farm and reports that two tanks of milk have been lost due to antibiotic failure. The pharmaceutical company will not accept responsibility for the bulk tank failure due to improper administration of the drug.

SEA meeting findings

Beth is mainly responsible for the small animals in the practice, and her other colleagues are responsible for the farm work.
She is on rota for farm animal emergencies; however, she is not up to date on all the drug protocols when it comes to large animals, and not up to date with the SPCs for all the medicines used.

Beth felt pressured from Mr Firth immediately on arrival to dispense the antibiotic with zero milk withhold; however, she remembered the discussion at the last vets’ meeting about the treatment protocol in regards to critically important antibiotics.

Although Mr Firth agreed with the treatment protocol, Beth felt she had to convince him to take the samples that were required. Throughout the visit Mr Firth was preoccupied with other matters on the farm, and was trying to get Beth’s opinion on them.

Beth did remind Mr Firth of the milk withhold and suggest that he write the information down; however, he informed her that he had a good system in place with the relief milker and a treatment whiteboard.

When asked at a later date, Mr Firth advised he did not receive any milk withhold advice, or instructions about administering the antibiotic. The PMS system showed that no batch numbers had been recorded.

Although Mr Firth had stated that a previous cow had been treated for mastitis, the PMS system showed this wasn’t the case.

Why did it happen?

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

System factors

• Due to the rota, a predominately small animal vet was covering emergency visits for large animals.

Human factors

• Beth was not confident or up to date with large animal drug protocols.
• Beth was distracted by Mr Firth’s conversation about his other commitments.
• Clinical notes were not recorded correctly at the time as Beth had other priorities.

Patient factors

• None.

Owner factors

• Mr Firth was preoccupied with other matters taking place on the farm.
• A zero milk withhold antibiotic was immediately requested to avoid any loss for the farm. Mr Firth assumed that Beth would dispense this due to his unfamiliarity with her.
• Mr Firth was not keen on the treatment protocol that was suggested.

Communication factors

• Beth and Mr Firth were both preoccupied with other matters and were not carefully listening to each other.
• Written instructions and advice were not given at the time or recorded in the farmer’s medicines book.

Other

• The dose rate given to 258 was correct; however, the maximum volume to be injected at one site, which was stated on the data sheet, was not observed, so the pharmaceutical company would not accept responsibility for the bulk tank failure.

What has been learned?

Beth was frustrated that she had not given the information to Mr Firth in writing. She felt she should have at least insisted that Mr Firth write the information down in his medicines book; however, it did not occur to her at the time, as she was keen to return to the practice.

A data sheet compendium or app should be available in all farm vets’ cars. All farm vets should have written paperwork to hand to farmers with batch numbers and withdrawal times, and critically important antibiotic advice sheets detailing the practice policy available in their cars.

Beth was praised for holding her ground with the critically important antibiotic protocol with a difficult client.

What has been changed?

CPD/training required

• All vets on the farm out-of-hours rota to receive further training on drug protocols for large animals.
• Reminder to all farm vets that batch numbers and milk withdrawal must be supplied in writing to farmers at time of supply or use.

New or updated protocols/checklists/guidelines

• Critically important antibiotic protocol to be redistributed to team members to reiterate importance.
• Visit protocols to be introduced.

Further audit required?

• Process audit to measure compliance of the visit protocols.

Other

• None.

Follow-up date

A follow-up date of 3 August 2020 was decided.