Errors in Veterinary Anesthesia

John W. Ludders, Matthew McMillan

• Publisher: Wiley-Blackwell
• Year: 2016
• ISBN:
  9781119259725
• Edition: 1
• Topic: Medicine
• Subtopic: Veterinary Medicine

Errors in Veterinary Anesthesia is the first book to offer a candid examination of what can go wrong when anesthetizing veterinary patients and to discuss how we can learn from mistakes.

• Discusses the origins of errors and how to learn from mistakes
• Covers common mistakes in veterinary anesthesia
• Provides strategies for avoiding errors in anesthetizing small and large animal patients
• Offers tips and tricks to implement in clinical practice
• Presents actual case studies discussing errors in veterinary anesthesia

CHAPTER 1
Errors: Terminology and Background

In effect, all animals are under stringent selection pressure to be as stupid as they can get away with.

P.J. Richardson and R. Boyd in Not by genes alone: How culture transformed human evolution. University of Chicago Press, 2005.

The rule that human beings seem to follow is to engage the brain only when all else fails—and usually not even then.

D.L. Hull in Science and selection: Essays on biological evolution and the philosophy of science. Cambridge University Press, 2001.

Error: terminology

Why read about taxonomy and terminology? They seem so boring and too “ivory tower.” When starting to write this section, I (J.W.L.) recalled a warm September afternoon many years ago when I was a first-year veterinary student at Washington State University. It was in the anatomy lab that my lab partner and I were reading Miller’s Guide to the Dissection of the Dog and thinking how we would rather be outside enjoying the lovely fall weather. At one point, my lab partner, now Dr Ron Wohrle, looked up and said, “I think I’m a fairly intelligent person, but I’ve just read this one sentence and I only understand three words: ‘and,’ ‘the,’ and ‘of’.” Learning anatomy was not only about the anatomy of the dog, cat, cow, and horse, it was also about learning the language of veterinary medicine.

Each profession or specialty has its own language—terminology—and the study of errors is no exception. Indeed, words and terms convey important concepts that, when organized into an agreed taxonomy, make it possible for those involved in all aspects of patient safety to communicate effectively across the broad spectrum of medicine. However, despite publication of the Institute of Medicine’s report “To Err is Human” (Kohn et al. 2000) in 2000 and the subsequent publication of many articles and books concerning errors and patient safety, a single agreed taxonomy with its attendant terminology does not currently exist. This is understandable for there are many different ways to look at the origins of errors because there are many different settings within which they occur, and different error classifications serve different needs (Reason 2005). But this shortcoming has made it difficult to standardize terminology and foster communication among patient safety advocates (Chang et al. 2005; Runciman et al. 2009). For example, the terms “near miss,” “close call,” and “preventable adverse event” have been used to describe the same concept or type of error (Runciman et al. 2009). Runciman reported that 17 definitions were found for “error” and 14 for “adverse event” while another review found 24 definitions for “error” and a range of opinions as to what constitutes an error (Runciman et al. 2009).

Throughout this book we use terms that have been broadly accepted in human medicine and made known globally through the World Health Organization (WHO 2009) and many publications, a few of which are cited here (Runciman et al. 2009; Sherman et al. 2009; Thomson et al. 2009). However, we have modified the terms used in physician-based medicine for use in veterinary medicine and have endeavored to reduce redundancy and confusion concerning the meaning and use of selected terms. For example, “adverse incident,” “harmful incident,” “harmful hit,” and “accident” are terms that have been used to describe the same basic concept: a situation where patient harm has occurred as a result of some action or event; throughout this book we use a single term—“harmful incident”—to capture this specific concept. Box 1.1 contains selected terms used frequently throughout this text, but we strongly encourage the reader to review the list of terms and their definitions in Appendix B.

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Box 1.1 Selected terms and definitions used frequently in this book.

• Adverse incident An event that caused harm to a patient.
• Adverse reaction Unexpected harm resulting from an appropriate action in which the correct process was followed within the context in which the incident occurred.
• Error Failure to carry out a planned action as intended (error of execution), or use of an incorrect or inappropriate plan (error of planning).
• Error of omission An error that occurs as a result of an action not taken. Errors of omission may or may not lead to adverse outcomes.
• Harmful incident An incident that reached a patient and caused harm (harmful hit) such that there was a need for more or different medication, a longer stay in hospital, more tests or procedures, disability, or death.
• Harmless incident An incident that reached a patient, but did not result in discernible harm (harmless hit).
• Latent conditions Unintended conditions existing within a system or organization as a result of design, organizational attributes, training, or maintenance, and that lead to errors. These conditions often lie dormant in a system for lengthy periods of time before an incident occurs.
• Mistake Occurs when a plan is inadequate to achieve its desired goal even though the actions may be appropriate and run according to plan; a mistake can occur at the planning stage of both rule-based and knowledge-based levels of performance.
• Near miss An incident that for whatever reason, including by chance or timely intervention, did not reach the patient.
• Negligence Failure to use such care as a reasonably prudent and careful person would use under similar circumstances.
• Patient safety incident A healthcare-related incident or circumstance (situation or factor) that could have resulted, or did result, in unnecessary harm to a patient even if there is no permanent effect on the patient.
• Risk The probability that an incident will occur.
• Root cause analysis A systematic iterative process whereby the factors that contribute to an incident are identified by reconstructing the sequence of events and repeatedly asking “why?” until the underlying root causes have been elucidated.
• System failure A fault, breakdown, or dysfunction within an organization or its practices, operational methods, processes, or infrastructure.
• Veterinary healthcare-associated harm Impairment of structure or function of the body due to plans or actions taken during the provision of healthcare, rather than as a result of an underlying disease or injury; includes disease, injury, suffering, disability, and death.

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Terminology in and of itself, however, does not explain how errors occur. For that we need to look at models and concepts that explain the generation of errors in anesthesia.

Error: background

The model often used to describe the performance of an anesthetist is that of an airplane pilot; both are highly trained and skilled individuals who work in complex environments (Allnutt 1987). This model has both advocates (Allnutt 1987; Gaba et al. 2003; Helmreich 2000; Howard et al. 1992) and detractors (Auerbach et al. 2001; Klemola 2000; Norros & Klemola 1999). At issue is the environment of the operating room, wh...

Table of contents

• Cover
• Title Page
• Table of Contents
• Preface
• Acknowledgments
• Introduction
• CHAPTER 1: Errors: Terminology and Background
• CHAPTER 2: Errors: Organizations, Individuals, and Unsafe Acts
• CHAPTER 3: Reporting and Analyzing Patient Safety Incidents
• CHAPTER 4: Equipment and Technical Errors in Veterinary Anesthesia
• CHAPTER 5: Medication Errors in Veterinary Anesthesia
• CHAPTER 6: Errors of Clinical Reasoning and Decision-making in Veterinary Anesthesia
• CHAPTER 7: Errors of Communication and Teamwork in Veterinary Anesthesia
• CHAPTER 8: Error Prevention in Veterinary Anesthesia
• APPENDIX A: Suggested Readings
• APPENDIX B: Terminology
• APPENDIX C: ACVAA Monitoring Guidelines
• APPENDIX D: ACVAA Guidelines for Anesthesia in Horses1
• APPENDIX E: A Brief History of Checklists
• APPENDIX F: FDA Anesthesia Apparatus Checkout1
• APPENDIX G: Association of Veterinary Anaesthetists Anaesthetic Safety Checklist
• APPENDIX H: Critical clinical condition checklists
• Index
• End User License Agreement