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
 

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
 

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

 

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
 
 

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
 

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.