Elevate Your Patient Safety: Learning from Errors, Systems-Based Approach, Managing Errors, Event Impact, and Working with Pharmacies

Finding the Black Box: Learning From Medical Errors (Part 1)

Recording Duration: 50 minutes
Interactive Course Duration: Approximately 75 minutes

Speaker Intro: Dr. Melinda Larson did her rotating internship and internal medicine residency at BluePearl in Tampa, and she led the Internal Medicine service in the BluePearl Clearwater hospital for eight years before becoming the Director of Medical Quality for BluePearl Pet Hospitals in 2022. Clinically, her interests include ultrasound, endocrine disease, and mentoring interns and residents; with her current role, she is most passionate about increasing awareness of the importance of patient safety science and continuous learning and improvement.  

Speaker Intro: Dr. Richard Stone is a Diplomate of the ACVIM (small animal internal medicine) and is the Chief Medical Officer for BluePearl Pet Hospital.  He has a strong interest in driving scalable improvements in medical quality, patient safety, and healthcare team performance.  Dr. Stone has worked in conjunction with the BluePearl medical quality team to implement patient safety advancements and medical quality standards across 100+ hospitals nationwide.

Session Description:

Calculating a sedative dose based on a body weight in pounds instead of kilograms. A patient has a prolonged hospital stay for fluid overload after their fluid pump is set for 100 mL/hr instead of 10 mL/hr. Forgetting to review a radiology report and missing the diagnosis of a metastatic pulmonary nodule. A positive urine culture gets overlooked, and antibiotic therapy is delayed. Intrapulmonary placement of an NG tube results in pneumothorax, an emergency chest tap, and ultimately patient death.

When things go wrong, it is human nature to quickly point fingers to save face. But blaming others or hiding our own medical mistakes out of fear of judgement only conceals vital data we need to learn from error. Like seeking the coveted black box following a plane crash, comprehensive analysis of medical errors is imperative in determining the root causes of these events. In learning from these mistakes, changes to prevent future error can be implemented. In this two-part discussion, we will provide a brief introduction to patient safety and medical error in veterinary medicine, share global patient safety data from hundreds of veterinary hospitals, and have a candid exploration of several real-life medical errors. We will also discuss a systems-based approach to patient safety event analysis and provide specific tools you can take back to your hospitals to improve the quality of care for your patients.

A Systems-Based Approach to Patient Safety (Part 2)

Recording Duration: 50 minutes
Interactive Course Duration: Approximately 75 minutes

Speaker Intro: Dr. Melinda Larson did her rotating internship and internal medicine residency at BluePearl in Tampa, and she led the Internal Medicine service in the BluePearl Clearwater hospital for eight years before becoming the Director of Medical Quality for BluePearl Pet Hospitals in 2022. Clinically, her interests include ultrasound, endocrine disease, and mentoring interns and residents; with her current role, she is most passionate about increasing awareness of the importance of patient safety science and continuous learning and improvement.  

Speaker Intro: Dr. Richard Stone is a Diplomate of the ACVIM (small animal internal medicine) and is the Chief Medical Officer for BluePearl Pet Hospital.  He has a strong interest in driving scalable improvements in medical quality, patient safety, and healthcare team performance.  Dr. Stone has worked in conjunction with the BluePearl medical quality team to implement patient safety advancements and medical quality standards across 100+ hospitals nationwide.

Session Description: Calculating a sedative dose based on a body weight in pounds instead of kilograms. A patient has a prolonged hospital stay for fluid overload after their fluid pump is set for 100 mL/hr instead of 10 mL/hr. Forgetting to review a radiology report and missing the diagnosis of a metastatic pulmonary nodule. A positive urine culture gets overlooked, and antibiotic therapy is delayed. Intrapulmonary placement of an NG tube results in pneumothorax, an emergency chest tap, and ultimately patient death.

When things go wrong, it is human nature to quickly point fingers to save face. But blaming others or hiding our own medical mistakes out of fear of judgement only conceals vital data we need to learn from error. Like seeking the coveted black box following a plane crash, comprehensive analysis of medical errors is imperative in determining the root causes of these events. In learning from these mistakes, changes to prevent future error can be implemented. In this two-part discussion, we will provide a brief introduction to patient safety and medical error in veterinary medicine, share global patient safety data from hundreds of veterinary hospitals, and have a candid exploration of several real-life medical errors. We will also discuss a systems-based approach to patient safety event analysis and provide specific tools you can take back to your hospitals to improve the quality of care for your patients.

Recognizing and Managing Medical Errors and Adverse Events

Recording Duration: 50 minutes
Interactive Course Duration: Approximately 75 minutes

Speaker Intro: Ladan Mohammad-Zadeh completed an internship and residency in Emergency and Critical Care at Angell Animal Medical Center.  She worked at Dove Lewis Emergency and Specialty hospital in Portland OR for 12 years before transitioning to consulting work. She is currently involved in educational work with ACVECC and VECCS, serves on the ACVECC Veterinary Committee on Trauma, and is a RECOVER CPR instructor. Her consulting work focuses on teaching, mentoring and education.

Session Description: Medical errors and adverse events unfortunately can be commonplace. Many hospitals do not have safety committees or an organized focus on patient safety. Sentinel event logs and follow up is often lacking in these settings. This session aims to relay the different types of medical errors and adverse events and discusses predisposing factors. The participants will gain an understanding of how to properly identify, document and follow up on errors and adverse events within the hospital. We will also discuss how to communicate these events with clients. The session will focus on some common errors and culture issues that can make reporting challenging.

Patient Safety Event Impact and the Role of Personal Resilience, Good Leadership and a Psychologically Safe Culture

Recording Duration: 50 minutes
Interactive Course Duration: Approximately 75 minutes

Speaker Intro: Rochelle completed her DVM at the Western College of Veterinary Medicine, Canada, an ECC residency at Angell Memorial, a masters in healthcare leadership at Brown University and a masters in Quality and Patient Safety at Johns Hopkins. Her current role at Mars Veterinary Health is focused on patient safety, patient care and ultimately patient outcomes. She currently works with the MVH Global Patient Safety Team to build a patient safety culture and support teamwork and safety in hospitals. She lives on a small farm in Bend, OR with her husband, 5 pitbulls, alpaca, sheep, horses and chickens. 

Speaker Intro: Jennifer Adler is a practicing internist in the Philadelphia area. She has held central positions in Medical Quality and Patient Safety at two large, multipractice organizations in the past. She assisted these organizations in achieving their Medical Quality goals through the implementation of quality improvement initiatives, fostering medical excellence on an organizational level and managing the logistics of patient safety event reporting.  She is now an independent consultant in Patient Safety and has been recently assisting Mars Veterinary Health in sharing learnings with the veterinary community.

Session Description: We will discuss the impact of patient safety events on individuals and the hospital team. Concepts such as ‘second victim, culture of safety + psychological safety’ will be discussed. Importantly, key ways to mitigate the impact of patient safety events on healthcare workers will also be presented.

Working with Pharmacies: Improving Communication and Reducing Errors 

Recording Duration: 50 minutes
Interactive Course Duration: Approximately 75 minutes

Speaker Intro: Dr. Kate Boatright has been in small animal practice since graduating from the University of Pennsylvania in 2013. After nearly 8 years of full-time practice in both general practice and emergency clinics, she moved to part-time clinical work to pursue her passion for educating veterinary professionals as a freelance speaker and author. Dr. Boatright enjoys discussing mentorship, the unique challenges facing recent graduates, wellness, and the spectrum of care.

Speaker Intro: Dr. Forsythe is a Clinical Assistant Professor of Pharmacy and the Pharmacy Service Head at the University of Illinois Veterinary Teaching Hospital.  She is also a diplomat of the International College of Veterinary Pharmacists. Dr. Forsythe graduated from the University of Findlay, College of Pharmacy in 2015 and completed her veterinary pharmacy residency at Purdue’s Veterinary Teaching Hospital.

Session Description: There is a growing need for veterinarians to partner with community pharmacists to maximize patient health and client satisfaction. Both professions want the best possible outcome for patients while fulfilling their legal and ethical professional duties. Because community pharmacists are not trained in veterinary pharmacology as part of their core education, problems can arise when there are large differences in dosage or side effects of the same drug in animals and humans. Join a practicing private practice veterinarian and licensed pharmacist as we discuss the current state of pharmacy issues. We will discuss common sources of error, steps that veterinarians can take to prevent these errors, and techniques for building successful working relationships with community pharmacists.