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Safety Culture with Dr. Lydia Love - Ep. 9
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If you practice medicine long enough, you may find that mistakes can happen despite our best efforts. Although anesthesia is vital to provide appropriate care in many clinical situations, it also has the potential to create adverse side effects, complications, and even life-threatening situations. For this reason, veterinary professionals providing anesthesia services should strive to promote a culture of patient safety within their practices. If this is a concept you have not heard before, or if you are a policy geek who gets excited over checklists, then this episode is for you!
Host Dr. Bonnie Gatson is joined by Dr. Lydia Love, a boarded veterinary anesthesiologist from North Carolina State University College of Veterinary Medicine and a strong advocate for patient safety in anesthetic practice. Together, they will discuss various aspects of patient safety, including what a hospital with a robust culture of patient safety looks like, why safety culture is important for the well-being of both patients and veterinary practitioners and why you need to fill your veterinary practice with checklists.
We invite you to check out articles and checklists that are referenced in the episode, including the original WHO Surgical Safety Checklist, the Association of Veterinary Anaesthetists (AVA) resource on checklists, and the Royal College of Veterinary Surgeon’s site on everything you need to know about implementing a veterinary surgical checklist, which includes examples and templates.
If you like what you hear, we have a couple of favors to ask of you:
- Subscribe to the North American Veterinary Anesthesia Society (NAVAS) for access to more anesthesia and analgesia educational and RACE-approved CE content.
- Spread the word. Share our FB or IG post, re-tweet, post something on a network or a discussion forum, or tell a friend over lunch. That would really help us achieve our mission: Reduce mortality and morbidity in veterinary patients undergoing sedation, anesthesia, and analgesia through high quality and peer-reviewed education.
Thank you to our sponsor, Dechra - learn more about the pharmaceutical products Dechra has to offer veterinary professionals, such as Zenalpha.
If you have questions about this episode or if you want to suggest topics for future episodes, please reach out to the producers of this podcast at education@mynavas.org. Please consider subscribing, liking, leaving this podcast a review, or even telling your friends to give this podcast a listen. We appreciate any and all listener support!
All opinions stated by the host and their guests are theirs alone and do not represent the thoughts or opinions of any corporation, university, or other business or governmental entity.
The NAVAS Podcast is published monthly on or near the 15th of the month.
Special thanks to Chris Webster for editing, producer Maria Bridges and Saul Jimenez for IT support in making this podcast a reality.
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Transcript
Introduction and Importance of Safety Culture
00:00:06
Speaker
Hello and welcome to all the gas pastors out there. I am your host, Dr. Bonnie Gatson, with another episode of the Navas podcast, where we take a deep dive into topics related to veterinary anesthesia and pain management. I'm really excited about this episode because I get a chance to get on my soapbox for a while to discuss an incredibly important, but oftentimes overlooked aspect of practicing anesthesia.
00:00:33
Speaker
which is creating a robust safety culture wherever it is that you practice. Now on its face, this issue might not seem incredibly exciting or intriguing. However, let me break it down this way. Think of something that is somewhat complex, that's a task that you do every day. Maybe something like making dinner for your entire family.
00:00:58
Speaker
It may be routine to you by now so that you barely think about it, but think about all the steps that go into making a meal. You have to decide on what you're going to make, find scrounging around in your kitchen, or you have to buy all the ingredients and then put them together in such a way that you create an edible and hopefully nutritious meal that doesn't poison your entire family.
00:01:27
Speaker
Transitioning an animal between consciousness and unconsciousness takes an entire system of incredibly complex steps, and making a simple error or miscalculation may lead to dire consequences.
Minimizing Human Error in Anesthesia
00:01:44
Speaker
How can we as anesthetists practice the art of anesthesia while ensuring that we do right by our patients to minimize the impact of human error on patient outcomes? If an error does occur, how do we protect ourselves from shame and destructive thoughts while simultaneously finding solutions to improve upon the system in which we practice?
00:02:13
Speaker
Our guest,
Dr. Lydia Love on Patient Safety Culture
00:02:14
Speaker
Dr. Lydia Love, a veterinary anesthesiologist from North Carolina State University, is here to help guide us through these important questions through her fierce passion in advocating for safety culture in anesthetic practice.
00:02:32
Speaker
Hi, Dr. Love. Thank you so much for joining us today on the NavVis Podcast. Hey, thanks for having me. I'm glad to be here. Let's just start with a quick introduction. So who are you? What do you do? And describe your level of training.
00:02:45
Speaker
Well, my name is Lydia Love and I am a clinical anesthesiologist at North Carolina State University College of Veterinary Medicine. I graduated from the University of Tennessee in 2002. I did a rotating small animal internship. I worked for the Humane Society of the United States for four years doing spay and neuter in rural Appalachia in a mash style kind of setup. And that got me really interested in anesthesia, taking care of
00:03:14
Speaker
30 or 40 or 50 or 60 dogs and cats in a day and getting them through that event safely. So I went back to the University of Tennessee and completed an anesthesia residency. I was board certified in 2010. And then I spent almost a decade in a private referral practice in northern New Jersey. And then I've been at North Carolina for about four years.
00:03:39
Speaker
I try to ask this to all of our guests. Why did you decide to become an anesthesiologist? What is it about anesthesia that really makes you feel passionate? Well, anesthesia is patient focused and that is my major professional driver. I want to improve and really just optimize the experience for our patients when they're under our care. I think that's going to be a very nice
00:04:06
Speaker
sidestep into our conversation today. And really why I had you on is because you helped to create the NavVis blog that exists on the NavVis website. And I think one of the first articles that came up on the blog was about checklists.
00:04:26
Speaker
And I thought your article was really well done and a great introduction to what we're going to talk about today, which is patient safety culture in anesthetic practice. So let's just start with some very quick, how would you define safety culture and what do you think are its fundamental aspects?
00:04:50
Speaker
There are like detailed definitions of patient safety culture in the literature, but they're kind of wordy. What I like to think about is that patient safety culture is the way people act, behave, and feel on a day-to-day basis as it relates to patient
Establishing Strong Safety Culture in Veterinary Practices
00:05:10
Speaker
safety. You can kind of think of it as the way we do things around here. And we all have patient safety cultures already.
00:05:17
Speaker
We just may not have really thought about what they look like. We may not have consciously shaped them into positive environments. We have a way we act, think, feel, and behave around patient safety. But I think that we're just starting to realize in veterinary medicine that we need to approach that creation in a really thoughtful manner in order to make it a positive space.
00:05:43
Speaker
That's really interesting. I guess I never thought about the link between advocating for patient safety linked very closely with kind of the culture of the practice. When I think of patient safety, I think of, well, we're going to implement this policy and that is going to relate into this patient outcome. But what it sounds to me like you're advocating for is more of
00:06:08
Speaker
a culture across the board or the environment that patients are operating in.
00:06:14
Speaker
Yeah, I mean, it has to be kind of forefront of mind in everything we do and at all levels of the organization. And so the fact is that a positive patient safety culture, it's bigger than just anesthesia alone, although I think anesthesiologists and anesthetists are really good drivers of that environment because, you know, anesthesia is not generally a therapeutic thing. It's
00:06:39
Speaker
It's often just a risk that has to be undertaken. And so we tend to be very patient safety focused to begin with. But the reality is that health care itself is dangerous. It presents risk.
00:06:54
Speaker
humans are imperfect, no matter how hard we try, no matter how smart we are, no matter how well-trained we are, things still happen all the time. And so an organization that has a positive patient safety culture is one where that risk is noted, everybody is aware of it, and everyone is empowered to speak up, to talk about things that go wrong, and to come up with systems fixes
00:07:23
Speaker
to hopefully trap error and prevent the same things from happening over and over and over. It's so important because one that hopefully improves the experience for patients, but it also improves the healthcare provider experience. It improves our wellbeing to work in a positive patient safety culture where it is acknowledged that things can go wrong and it's often the system's fault, not that we're terrible people.
00:07:49
Speaker
Yeah. Okay. You said a lot of things in there that I want to break down and talk about a little bit more. I get real excited. Yeah. Okay. So let's just start with why are anesthesiologists in general, kind of the leaders in addressing patient safety, performing anesthesia in patients on a daily basis,
00:08:07
Speaker
that probably just makes up a very small percentage of what people are doing in daily veterinary practice. Yet anesthesiologists, at least I know for me, when I come into a practice a lot of times,
00:08:22
Speaker
People in the practice are looking to me towards being a leader in helping to address issues specifically related to patient safety.
Understanding Errors: System vs Human
00:08:31
Speaker
And so what is it about in ascetic practice encourages the creation of a robust safety culture?
00:08:38
Speaker
I think anesthesiologists make great medical directors and great patient safety officers for a reason. And that's because we do something on a day-to-day basis that involves CNS and cardio respiratory toxins, right? These are the drugs that have the narrowest therapeutic index of any routinely used medication in healthcare practice. And so we're giving toxins, we're presenting extra risk to the patient.
00:09:06
Speaker
necessary in order to achieve our goals, whatever the procedural goal is. It's necessary in order to do that in a humane way, but it does present risk. And so we are a group of people who are already focused on patient safety and have made great strides over the last few decades. But still, I do think anesthesia is one of the main drivers of patient risk and liability in the veterinary health care space.
00:09:33
Speaker
Another thing I kind of wanted to touch on is something that you mentioned in your previous answer about sources of medical error. I always think of medical error as something that is atrogenic, meaning something that we do as practitioners, and that it ultimately leads to some kind of patient harm, whether that be just a minor harm or a significant harm that can lead to patient death.
00:10:02
Speaker
And you mentioned that your medical errors can kind of be divided into like a knowledge base error, meaning like you just didn't know that you did something wrong, but there can be system errors. And so I think most people blame medical errors on
00:10:19
Speaker
lack of knowledge base and like a more active type of error. But there are so many system errors that can occur that can result in a patient safety or a medical error issue. So I'm just wondering if you can think about some examples of some of these system errors so that our listeners can start thinking about them as far as ways to address them in their own practice.
Communication and Hierarchy in Safety Culture
00:10:43
Speaker
Yeah, well, it's really a social science theory that was put forth by a psychologist named James Reason. So James Reason put forth the Swiss cheese theory of error development. And essentially there are multiple defense layers that start with the system we work in.
00:11:03
Speaker
So thinking about things like, is there enough staffing? Is there the right equipment? Does the equipment work correctly? Have we been trained appropriately on the equipment? Do we have two drugs that look like each other that are stored next to each other? Do we have policies such as labeling drugs when they're drawn up into syringes? Those are systems things that can either promote or prevent error
00:11:32
Speaker
And then at the kind of sharp end of the stick there are human errors there are knowledge based errors there are lapses in judgment there are things like being rushed or you know maybe i had a fight with my partner for i came to work and so now i'm sort of not emotionally where i might perform the best there's all these human things that can happen the thing is i can't ever be perfect.
00:11:58
Speaker
No matter how hard I try, I will still make mistakes. And so in order to prevent mistakes from hitting the patient in these complex and time-sensitive systems, we have to use systems changes to trap those errors, because I can potentially perfect the system. I can't perfect people. So I want to move on to what we know about safety culture in veterinary medicine, because I feel like it's pretty well documented and studied.
00:12:27
Speaker
in human anesthesia. In fact, there's a whole anesthesia safety foundation that exists on the human side. From what I've read, I know that there are some very strong benefits and some strong knowledge that we have gained from studying human anesthesia. What do we know about veterinary medicine? I guess the first question is, do we know whether or not veterinary practitioners even consider
00:12:53
Speaker
or take seriously safety culture in their practice? Do we have any information on that? We have a little bit. There are a couple of studies, one by Catherine Oxtoby and then one that I helped with at North Carolina that are surveys looking at patient safety culture. So what is the culture in this organization or in this section of veterinary medicine?
00:13:19
Speaker
at that time period. Dr. Oxtoby developed the Nottingham Veterinary Patient Safety Culture Survey, and then I adapted it specifically to NCSU. So an academic institution in the US is going to be a little bit different from various practices in the UK. In our survey at North Carolina State, we mostly had positive responses about how people felt about patient safety culture in that organization, but there were certain themes that are commonly found
00:13:48
Speaker
in human medicine as well. So things like a strong hierarchy actually prevents speaking up.
00:13:55
Speaker
So when people feel like they're gonna be judged or looked down upon by somebody who's higher up in the hierarchy, they don't talk about things that might be happening or things that they don't understand why they're happening. And that's a problem for patient safety when people don't feel they can speak up. And then communication breakdown is really common. And we also know that from a study published out of Cornell where they documented the types of errors that occurred within their hospitals,
00:14:25
Speaker
that communication error is one of the most common that happened. And so we have some information that kind of dances around the edges of patient safety culture within veterinary medicine, but we certainly don't have the degree and amount of literature that is available from the past three decades of study in human health care.
00:14:44
Speaker
So yeah, when I go into veterinary practices, something I see about the hierarchy issue is that people are also scared of retribution. They feel like their job is on the line sometimes and they don't want to speak up or anchor people who might even, you know, be their employer. As far as the communication errors are concerned.
00:15:02
Speaker
Do you know what types of communication errors are happening that are more likely to lead to patient harm? Like do we have any information about the types of errors specifically in communication or is it just like a hierarchy thing? Are there other types of communication?
00:15:18
Speaker
Yeah, I mean, I think there's all types of communication errors. So like in big institutions, information may not get transferred between services. That can easily happen. In smaller institutions, information might not be communicated between shifts, right? We don't have structured patient handoffs.
00:15:37
Speaker
often in veterinary medicine. And then, oh, I forget to tell the next person that we put off giving this drug at this time because of whatever reason, and then that drug never gets given. Or I forget to say that there was a little bit of free fluid found in this hit-by-car patient's abdomen. We mean to recheck it again in a few hours.
00:15:59
Speaker
I don't tell the next shift. It doesn't happen. Death gets missed. Then the animal gets sicker. Those types of things, all types of communication can be problematic. And to that end, the tools of a positive patient safety culture include checklists, structured patient handoffs, things that we can use to trap error and improve communication amongst health care providers. Excellent.
Creating a Robust Safety Culture: Practical Steps
00:16:24
Speaker
So I think this is going to lead into
00:16:27
Speaker
The next part, which is really practical steps that people can take to create more robust safety cultures in their practice. So do we have examples that you think that people can start thinking about when they're thinking about improving patient safety in their practice?
00:16:46
Speaker
Yeah, well, I would actually draw it back to what you said a few minutes ago about going into practices and finding that people are scared to speak up. The number one thing you can do as a leader within a practice is to create a sense of psychological safety and an ability for all team members to feel safe speaking up. And that includes things like respectful communication,
00:17:15
Speaker
Understanding that patient safety depends on every member of the team doing the right thing at the right time. That includes front desk staff, that includes kennel workers, that includes assistants, it includes technicians, it includes junior, veterinarians, and administrators. We all have to be able to support a safe, open, respectful environment for communication.
00:17:41
Speaker
So that's number one, I think. Number two is for an organization to realize that things go wrong and we need to talk about them. And so we need to do so both in structured and unstructured ways. So when things go wrong in a non-accusatory, non shame and blame way, either in a kind of a huddle, like a debrief, informal, kind of what went right, what went wrong, how do we fix that going forward?
00:18:07
Speaker
And then before things go wrong, we need to use things like checklists, like badges that say, I need clarity. Hey, I'm not sure what's going on here. I have a question. Let's stop for a second and talk about this before we rush forward into a mistake. Again, that respectful communication, anybody ought to be able to do that. Using structured patient handoff tools like I-PASS, which is a mnemonic for
00:18:35
Speaker
all of the things that need to be communicated when handing off a patient, employing those to hopefully avoid errors. In this talk, we could focus a lot on surgical safety checklist because we're anesthesiologists and this is the patient safety culture tool that really has the most literature to
Surgical Safety Checklists: Implementation and Effectiveness
00:18:53
Speaker
support it. Do you use a surgical safety checklist or an anesthesia safety checklist in your practice, Bonnie? I would say it depends on where I
00:19:02
Speaker
Practice because i have been doing this so long that i have a very systematic way that i go about before i do any animal.
00:19:12
Speaker
And I have a literal system in my head because I've been doing it for so long that I go like, okay, physical exam, blood work, I'm gonna make sure we have consent and then I'm gonna go through everything. So I personally don't do it every time. However, when I work at very busy institutions, I encourage strongly that the institution instigate a checklist.
00:19:37
Speaker
And the majority of places I go have some formulation of checklists. And the other thing, I have a lot of opinions on this, which we can get into in a minute, but one of them is that I do feel like when you have a pre-anesthetic checklist, it needs to be very specific to the individual practice. Because I have a business where I go into different practices, I do consulting work,
00:20:03
Speaker
And every practice has their own type of culture and their own type of specialty. So if I'm going to a cardiology center where they're only doing cardiac procedures, we're going to have a very different checklist than if I'm going into a dental practice and they're just doing dentistry all day. We can use very different checklists to identify the patient errors that are happening in each one of these practices more commonly and make sure we're asking questions before we start.
00:20:30
Speaker
I find when I started doing this, I would be like, you need to implement this checklist. This would be the checklist that I had for my academic institution. In private practice, this is three pages long. We don't have time for this and it doesn't seem relevant. I find that every practice I go to, I'll create a skeleton and I'll usually say, start with this,
00:20:53
Speaker
Let's try it and amend it over time. But something I think is important point is not only should you start doing it, but also make sure that you are engaging with your team to see how you can make it better.
00:21:07
Speaker
I guess I would encourage you and everyone to take that checklist that you have in your head and make it a conversation with your team, whoever your team is that day, because that's going to, again, empower everybody to be part of the process.
00:21:23
Speaker
So one thing that checklists do is make sure you do all the things, right? Make sure you do all the little things in a timely fashion. You haven't forgotten to get consent, things that apply to patient safety. You haven't forgotten to get the antibiotic before incision, et cetera, et cetera. But what they do that's actually a bigger deal is improve communication. Everybody in the room has the same information. You've articulated a perianesthetic plan and you're all working toward the same goal.
00:21:53
Speaker
you make a team of people out of the random group of people who happen to be there. So that's really where I think the power of checklist comes in. The next thing I wanted to talk about was the modifications to fit local practice. If you look at the World Health Organization surgical safety checklist, which is the foundational model for all of these, the bottom of it says modifications to local practice are encouraged.
00:22:18
Speaker
and your point that what works in cardiology versus what works in dentistry versus what works in C-sections versus what works in farm animal, very different. At NCSU, we actually have multiple checklists we use for different situations. At the end of a dental procedure, we need to do a really good oral exam, make sure there's not gauze stuffed in the back of the mouth or a whole bunch of fluid or whatever that we need to suction out. That may not be necessary at the end of a C-section, for example.
00:22:47
Speaker
And then the final thing I heard in your last statement that I think is really important and I'd really like to emphasize is the fact that you cannot just throw a checklist into a situation and not explain it and not get feedback and not get buy-in. That will never work. And that has been shown time and again in both the human and veterinary literature, actually. If you don't have training, engagement, buy-in, and feedback, the checklist is just another piece of paper that people don't read.
00:23:16
Speaker
Yeah, I totally agree with that. It has been somewhat of an uphill battle sometimes to get checklist implemented. And I think it's because exactly that. You're just telling people that this is another thing they have to do in their day, that they're already stretched thin, and that encourages people to discard it or not think of or take it seriously. So I totally feel that on a very personal level.
00:23:41
Speaker
I want to talk a little bit more about, we've been like skating around the topic by just saying like, oh, checklists, but where do we know checklists actually help? Which part of anesthesia, before anesthesia, during the surgery, after surgery, and then two, like how long should people be dedicating or how many minutes do we think we really need to be dedicating
00:24:04
Speaker
to these checklists at each phase of the checklist. The foundational model, again, is the World Health Organization surgical safety checklist. It is a three-part, 19-item checklist that grew out of the Joint Commission's universal protocol. So the Joint Commission is the organizational body that accredits human hospitals in the United States.
00:24:24
Speaker
You have to be accredited by the Joint Commission. Their universal protocol is a pause right before incision to make sure that you have the right patient, the right site, and the right surgery because those are sentinel events. If you operate the wrong patient, you do the wrong surgery or operate the wrong site. Those are
00:24:44
Speaker
Those are never events, essentially. So that's been in place for a long time. The World Health Organization, as part of their second global patient safety challenge, investigated the use of a three-part surgical safety checklist. So just prior to induction, just prior to incision, and just prior to everybody running out of the OR, a pause in the workflow,
00:25:07
Speaker
Should be about maximum a minute, ideally 45 seconds, 30 to 45 seconds to run through, make sure everybody has the same information. You've done all the little things. If it takes longer than that, it's because you've reached a hard stop. So, oh, we actually haven't given the antibiotics before incision or prior to induction. Oh, this patient doesn't have a identification collar on. I need to make sure this is the right patient.
00:25:33
Speaker
or I haven't checked the anesthesia machine, whatever it is, hard stop, then it takes longer. But if you've done everything, it should take about 45 seconds. So the information we have about that is relatively limited in veterinary medicine. In human medicine, that original study indicated that all complications
00:25:52
Speaker
including mortality were reduced by 40% with the implementation of this surgical safety checklist, both in high and low income countries. And that's awesome because it is not an expensive piece of equipment that veterinarians can't afford. This is a thing you can do tomorrow. You know, once you talk to your team about it, we can all do this. And so, so that's really cool. What we know in veterinary medicine is a little
00:26:22
Speaker
bit less because we often don't have the money to do those kinds of studies, but it has been shown to reduce surgical site infection, the use of a checklist in veterinary patients, surgical safety checklist. It also reduces complications overall and unplanned return to the OR.
00:26:43
Speaker
So that's the information we do have. Also, people generally feel good about them. So there have been two recent studies that surveys that looked at practitioner awareness and attitudes towards surgical safety checklist, both in the UK and in the US.
Checklist Awareness and Implementation Guidance
00:26:58
Speaker
So the one in the US was just recently published in JAVMA and the one in the UK was recently published.
00:27:03
Speaker
think in veterinary record, but they're very similar studies in both of those. Well, it's actually really interesting in the UK, about 60 to 70% of practitioners were familiar with surgical safety checklists. Most people use them in the US. Only about 20% of the people surveyed knew about them. Wow. So it's really interesting that we're at this point, but I think this is the tipping point. I think enough people are talking about it and I think we're getting there.
00:27:33
Speaker
Of the people who were familiar with them, most people used them most of the time, and they felt positively toward them. They felt that they improved communication and improved their workflow.
00:27:43
Speaker
Do you know off top of your head, because I know, aha, they do accrediting. Do you know if in their standards they have the use of checklists? Actually, it's a great question. I know that they are mentioned in their aha anesthesia guidelines. I do not know if they are part of the accreditation standards.
00:28:04
Speaker
course it is a voluntary accreditation, right? Like it's not required. Yeah. I just didn't know if it was a part of their anesthesia recommendations or not. Definitely mentioned in their guidelines, uncertain if it's part of the standards. So if you are a technician or a veterinarian listening to this podcast, how do you go about
00:28:24
Speaker
making that change in your practice? Where can people find checklists? Maybe there's pre-printed checklists, as you mentioned, through the World Health Organization. But how do we find these checklists? And what are the best ways of getting your team on board to start implementing one of these things tomorrow?
00:28:40
Speaker
Yeah, the second question is really important because a checklist is not going to fix a broken culture. That tool can't do it. And so what you have to do is start with the culture and culture is both top down and bottom up. So administration, whatever that looks like in your organization, whether it's a single practice owner or a team of, you know, 50 people administration has to be on board.
00:29:05
Speaker
with what a positive patient safety culture looks like. But the attitudes we bring to work matter too. So when I say we, I mean, I'm not in charge of anything, but how I behave in regards to those around me and the creation of psychological safety, that is important on a day-to-day basis.
00:29:24
Speaker
So one, you have to support that positive patient safety culture, both top down and bottom up. And then two, specifically for some of these tools, I think the World Health Organization Surgical Safety Checklist is a good place to start, and then modifying it pretty dramatically to your practice. The Association of Veterinary Anesthetists, the AVA, which is sort of like the novice European sister organization, we are modeled on their organization
00:29:52
Speaker
They have veterinary-specific checklists that are freely available on their website. You can modify those. And there are various other resources. People have published checklists that they use in proceedings and things like that that, you know, really just a quick search of the internet can get you started there. Yeah. In the show notes, I'm going to link both the ABA as well as the World Health Organization's
00:30:17
Speaker
surgical checklist, so if you're just looking for a place to start, look in the show notes. So, earlier we talked a little bit about issues with communication and people speaking up when they feel like something is wrong.
Balancing Safety Culture and Accountability
00:30:30
Speaker
The one thing I oftentimes hear from administrators, and again, I'm not an administrator by any means, I'm not in charge of anything, but one thing I sometimes hear from administrators is if people are making mistakes in practice,
00:30:44
Speaker
They want to have a way of making sure that that individual is not continuing to make mistakes. So I find a lot of times that administrators are reprimanding people, if they make a mistake, as a way of documenting whether or not that person can continue to be employed at that particular place. And so there's a punishment system. So if a technician forgets to give a medication, then they were supposed to, or they gave a wrong dose,
00:31:13
Speaker
of a medication, a lot of times administration is going to respond to that with some kind of either a verbal or written reprimand, again, as a way of documenting employment and things like that, kind of protecting the institution. So how do you balance between creating a robust safety culture in a practice where people can speak up if they do make a medical error?
00:31:36
Speaker
versus making sure that the practice can protect itself against employees or like bad actors essentially in an employment setting.
00:31:44
Speaker
I mean, it's such a great question and it feeds into the idea of a just culture. So in a just culture, people are not shamed and blamed, but they are still responsible for their actions and they have professional responsibility, meaning they have to follow policies, right? They have to do the things that are expected of them, show up on time, be a respectful communicator, not show up to work impaired, things like that that would be problematic in nature.
00:32:14
Speaker
And the organization has to as a conscious effort realize that mistakes can happen even with the best intent and then not punish people but look at the system and how it can be fixed.
00:32:31
Speaker
It is one thing to do something maliciously or to, again, choose not to follow a policy. And it is another thing to accidentally give the wrong drug when you were not at all trying to do that. And if you punish people for that kind of thing, you will isolate them.
00:32:49
Speaker
You will hurt them emotionally. You will potentially lose a worker, which is really potentially problematic. And you will do nothing to raise organizational level outcomes. You will just allow that thing to happen again to someone else and go through the same cycle over and over. Whereas if you support the person who made a mistake appropriately and then fix the system, you can hopefully all votes.
00:33:19
Speaker
Yeah. So what I'm hearing from you is if somebody makes a mistake trying to get to the root cause of why the mistake happens, create maybe protocols to try to prevent that from happening again. However, maybe if that employee violates that protocol in the future, then that needs to be a different type of discussion at that point. Is that what I'm hearing? Absolutely. Like violations and malicious acts are different than mistakes, right? Right. Okay.
00:33:47
Speaker
I kind of feel the same as you, but I just wanted to hear from your perspective, but I think you did a beautiful job kind of addressing that very delicate balance between making sure that the employer is kind of protected from malicious employees. Malicious employees sounds so mean, but, and then making sure people don't feel this like blame culture coming at them in their day to day job.
00:34:10
Speaker
Okay, so beyond checklist, are there other types of safety protocols that can be implemented that are very low cost that we know can help really create this robust safety culture?
Incident Reporting and Systemic Improvements
00:34:23
Speaker
Yeah, I mean, I think one of the first steps is to implement some sort of reporting system, right? Because if you don't know what's happening, then you can't fix it. Yeah. So what we've done at NCSU, what I know they've done at Cornell, what I know is happening in Illinois and also at Florida is a digital centralized safety reporting system.
00:34:48
Speaker
Now, it doesn't have to be that fancy, you know, if you're not in a big organization. Oh, they also I know that Mars has implemented this both at Banfield and Blue Pearls. I'm not sure about BCA, but so you can just have a Google form or whatever that people could use to confidentially report either issues or potential issues so that you can, you know, see what are the themes and what do we need to address? I say confidential because anonymous is a little problematic.
00:35:18
Speaker
One, if it's anonymous, it's hard to get more information, hard to follow up with the person if they haven't provided everything. So there's that. And then also, unfortunately, if it's completely anonymous and your culture is less than perfect, which could be the case,
00:35:34
Speaker
Sometimes people will use that as a retaliation tool to report on somebody else. So confidential is probably better than anonymous in those situations. And then it probably just needs to go confidentially to one or two people who then decide whether it is appropriate to share with the group of people who would look at the systems and hopefully come up with ideas to improve things.
00:35:57
Speaker
Yeah, when I worked at the University of Florida, we did have a incident reporting system that we took from Shands, which is the human hospital at the University of Florida.
00:36:08
Speaker
And we did exactly what you were saying, but something else that I think is important if you're creating this reporting document is that we would also encourage people to use it to report near misses, meaning like if there was an error and then it was caught and
00:36:27
Speaker
There was no patient harm that occurred as a result. Then we still wanted that to be reported because it would show us policies that were working and also would help to highlight like if we instituted a policy.
00:36:43
Speaker
And for maybe we had like one incident and then we instituted some kind of policy and then that policy wound up causing more harm or it's very time consuming or something like that. We could identify it and get rid of it. The fact that you are so naturally aware of all the things to do right, I think just highlights the fact that anesthesiologists are great at creating positive patient safety cultures. If you just look at all the things that go wrong,
00:37:09
Speaker
For example, if you only look at the way planes crash, you don't learn how to fly the plane. Yeah. And so looking at harmless hits and near misses does exactly what you said, which is how do things go right? Yeah. And that's important too. Oh yeah. I also had a random question about drug labels.
Preventing Medication Errors and Enhancing Safety Culture
00:37:26
Speaker
So I always strongly encourage practices to implement drug labels. Some practices are very hesitant in doing that because
00:37:35
Speaker
They feel like they have to go buy drug labels, which there are like pre-made drug labels for opioids and for induction agents and things like that. And they're color coded. So like opioids are blue, for example, neuromuscular blocking agents are usually like striped in some way.
00:37:51
Speaker
And the thought is that if they're color-coded, there is this extra layer of cognitive aid whereby if you're grabbing drugs from a random pile and you know like opioids are blue, you're going to make sure you grab a blue label. Now, what I find going into practices is they're not super keen on this other expense, but they want to try to implement something.
00:38:12
Speaker
So I've actually encouraged people to just buy labels from Office Depot, like regular old white labels and write the name of the drug on the label or even print it from a printer system. If they know like they use like five drugs in practice, just print it off a label sticker. But I have gotten to debates with people about the lack of color coding in the drug label. So if you do that, then all of your drugs are going to be the same white color.
00:38:39
Speaker
because they're all white office labels. So do you have any comments on that? Like how important is it for that additional cognitive aid or is just like creating drug labels in any way just like really going to help?
00:38:52
Speaker
Yeah, I mean, I think that labeling medications is basic medication safety that has been in human health care for decades. And the fact that we still have to have this conversation is honestly a little bit disappointing. But it's a different ethical and economic environment in veterinary medicine, right? And so I hear you, the practice I went into in New Jersey wasn't labeling anything. I got a lot of pushback about buying the color coded labels.
00:39:21
Speaker
It took a while. We eventually did it. I think the other problem with writing on them and not having, you know, so you don't have the color coding, you don't have that extra cognitive aid. Sometimes people's handwriting is terrible. So I am guilty. My handwriting is awful. I can't read it myself, you know, and then I'm likely to just put the first three letters of the drug. And so now I've got Dex and is that Dexamethasone? Is it Dexmenetomidine? Is it dextrose? Like, you know, so yes, I think that it would be best to have pre-printed color coded labels.
00:39:52
Speaker
And if economically that is not in the cards, then I think the white labels that you write on are a good first step. Yeah. I actually really agree with you about handwriting because I'm also in the bad handwriting club.
00:40:07
Speaker
And so I try to like encourage people if you're going to just buy the office labels, like just print them on a printer, you know, pretty low cost way of just making sure that you have like some kind of legible label. But yeah, I mean, I try strongly to discourage writing on syringes with Sharpies. Cause I feel like I think that's like going to be the answer.
00:40:30
Speaker
the low-cost answer, and I find that's also terrible because sometimes the Sharpie is on the plunger, sometimes it's on the side of the syringe, it gets wet, it smudges. And my least favorite thing in the world when I go into practices is when they pre-draw up flush syringes that they're going to use.
00:40:52
Speaker
and they're all in like a one location, which is excellent, but they all have the word F or something like written on the center. And that always bothers me because when you're in the middle of induction, I can't tell you how many times I've picked up like the Alfaxilone syringe and thought it was the flush because they're all in three CC syringes, you know? So I still try to encourage practices to put their drug labels even on
00:41:17
Speaker
saline or flushes or something even if you have like a yellow label and you just slap it out on anything that's yellow is a flush i mean anything that simple but yeah that always that always makes me crazy to bring your own labels with no but maybe i should
00:41:35
Speaker
I would have to, I would have to because it's just so easy to do the wrong thing. And that's what we have to do. We have to make it easy to do the right thing and hard to do the wrong thing. Yes. You're giving me all these, these like ideas. I was like, yeah, I don't have my own personal checklist. Like maybe I should. The other thing that personally, I think that you can recommend to like improve patient safety. Um, something simple, like I work at so many practices that never pressure check or leak check their anesthesia machines. So many.
00:42:04
Speaker
I feel like your mind is. No, I know that I mean, I'm aware of the state of veterinary anesthesia and I'm aware that there are many of us out there working hard to improve it. Again, it's such a, an area of risk for our patients. And in my experience in practices, it's not the fancy things.
00:42:29
Speaker
need to be done to improve patient outcomes. It's the little things like checking your anesthesia machine before every patient every time. You know, the anesthesia machine introduces a complicated set of risks to the patient. It is a necessary thing, though, that we have to do to deliver inhalant anesthetics. And so using a machine checklist
00:42:52
Speaker
Every patient every time should be basic anesthetic care, but there are no rules in veterinary anesthesia as you know. Right. So I would say from our conversation, if you had to pick like a handful of recommendations that are very simple that people can start doing tomorrow to improve anesthesia safety.
00:43:10
Speaker
And again, I agree with you about the communication with administration, but I feel like that's something that takes some time towards creating a different culture. But if we're just talking about something you could do tomorrow, from my conversation with you, I'm hearing we could do implement checklists, pressure check your anesthesia machine, and start using drug labels. Is there anything else that you can think of that people can start doing relatively quickly that will really enhance their safety culture in their practice?
00:43:37
Speaker
Honestly, I think the big thing is just talking about it. Start talking about it. Talk to your colleagues. Talk to people in all levels of the hierarchy. Encourage people to speak up and create that sense of psychological safety so that everybody feels like they're a part of the team.
Encouragement for Team Engagement and Continuous Improvement
00:43:55
Speaker
Yeah. Maybe if you're listening to this, you can volunteer yourself at your practice as your hospital's safety culture manager or something.
00:44:04
Speaker
Yeah, it's really the most important thing is shifting our approach to how we manage something that is inevitable, which is human error. Just curious, at NC State, do you guys have like a safety culture or a patient safety culture officer or something like that or safety officer? We don't have one like you all had at the University of Florida, but we have a team of volunteers
00:44:30
Speaker
who review the patient safety reports. And actually what we do is we meet once a week and we switch every about eight weeks. We change the group up so that somebody's whole life isn't taken over. So it's really interesting group of people. It's technicians, it's faculty members, it's administrators, it's librarians, it's anatomists. So it's not just people in the clinic because having outside perspective is amazing.
00:44:55
Speaker
And we meet once a week and just talk about the things that happen and what we can do to do things better going forward. How can we support both the providers and the patients in our organization? Yeah. And you know, I find that I'm just just my, my mind is going right now. I'm like, you know, it'd be so cool. It's like, if you work in like general practice.
00:45:13
Speaker
that you guys have like a safety meeting or something like that. Hopefully you're having team meetings in general, maybe even if it's like once a quarter, but even if you dedicate even a small portion of that meeting to like safety culture and coming up with like brainstorming as a team, coming up with ideas of like how you can start implementing some of these things to improve your culture. I mean, I think that would be amazing.
00:45:35
Speaker
Yeah, and I just I really love your point about brainstorming as a team. Because again, all of us, no matter what our job title is, we're all important to patient outcomes. Awesome. Well, Dr. Love, thank you so much for taking out some of your time today to talk to me about this really important issue. And I hope you have a great day. Oh, thank you for having me. I had fun.
NavAss Membership Benefits and Conclusion
00:46:02
Speaker
If you like what you heard today, I encourage you to check out NavAss and consider becoming a member. As a member of the North American Veterinary Anesthesia Society, you get tons of benefits, including access to CE events, focusing on anesthesia and pain management, blog posts, fireside chats with boarded anesthesiologists, as well as specialty technicians, and just so much more.
00:46:27
Speaker
visit www.mynavas.org to advance your anesthesia journey today. If you have any questions about this week's episode or the Navas podcast in general, or if you want to suggest topics you would like for us to discuss in future episodes, please reach out to us at education at mynavas.org.
00:46:50
Speaker
We would love to hear from all of you. Also, a huge thank you to our sponsor, Decra, without whom this podcast would not be possible. Visit their website, www.decra.com to learn more about their line of veterinary anesthesia products. I want to thank our guest, Dr. Lydia Love, again for this insightful discussion on patient safety culture.
00:47:20
Speaker
and a huge thank you to all the gas pastors out there who choose to spend their time with me today on the Navas Podcast. Becoming a skilled anesthetist is a lifelong journey of learning and self-discovery, so I hope you consider listening in the future. Until next time, I'm your host, Dr. Bonnie Gatson. Thank you for listening. I hope you consider tuning in next month for another episode of the Navas Podcast.