Good evening and welcome to tonight's Platinum webinar on the topic of established systems in your practise to reduce errors and to deal with them when they occur. A bit of housekeeping before we start. I'm sure many of you have joined us previously, but just as a reminder, we're joined by my colleague Luke tonight.
So if you do have any technical issues, please do type them in the chat box and we will then get to you and try and help you resolve any technical issues you may have. As our speaker, Pam is going through the presentation, if you have any questions come to mind, please do, jot them down in the Q&A box, and I'm sure we'll have a bit of time at the end to pose some of these questions to Pam. So, as I say, as we're going through, please do just jot them down and we'll come back to them at the end.
So, it's the Thursday before the Easter break. We've got some, hardy souls who have joined us, so it's great that, we have got people joining us. I wasn't sure whether people would be starting their, chocolate and alcohol commas, but no, we have got some, dedicated CPDs, which is great to see.
So a little bit about our, presenters for tonight, Pam. Pam Mosalle was a partner in a veterinary hospital for 17 years. She is now currently lead assessor for the RCVS practise Standards scheme.
She's also an SQP assessor for AMtra and organises CPD webinars for SQPs. So also if you've got any questions around SQP then that's something we can discuss at a later date, but Pam is your lady for that as well. She edits the BSAVA guide to the use of veterinary medicines and organises the BSA VA dispensing course.
Pam is very interested in clinical governance and in how improving systems can help reduce errors in veterinary practise. So I'm delighted that I'm able to hand over to Pam who will give talk you through establishing the systems in your practise to reduce errors and to deal with them when they occur. Over to you, Pam.
Thanks very much, Rich. Hi everyone, yes, welcome and well done for . Listening tonight when I think a lot of us are in, demob mode that we're hopefully getting a few days off over Easter, and I hope you're off and not on call over Easter.
And hope you get plenty of chocolate eggs and, but I suppose the other thing is lots of people be out on the road tonight driving to wherever they're going for Easter. But anyway, welcome to those of you here. So you notice that my title there is about reducing errors, because I don't think we can ever prevent errors.
What we can try and do is reduce errors, and we're going to talk all about systems to try and do that. So I don't know if, you saw the, headlines. That was only about, well, it's 23rd of February, it says in there, look, and it was all over TV and the internet about NHS medication errors, and they reckoned that those medication errors were causing 22,000 deaths every year, which is quite scary, and but these things do happen and it's very hard to prevent them happening completely.
So we're going to talk about ways of, of dealing with with with prescription errors amongst amongst other errors and putting systems in place to try and prevent them from happening. So what about errors in veterinary practise then? Well, I think you can classify errors, into human errors, system failures, and lack of communication.
And the main thing we're going to talk about tonight is system failures and ways to try and improve systems, because as, Rich said, I'm leadsessor of practise standards. So practise standards is a lot about systems of work, and that's the kind of thing we're going to talk about. But this picture is to remind me.
To admit to one of my errors, and this is just one of my errors, and this one I made when I was a new graduate. This is one I made when I was a long way into my career. It was, this is not an actual X-ray of that case, but just to remind me, it was a, German Shepherd with a bleeding splendid, splenic tumour in the middle of the night, haemorrhaging massively when it was opened up, and I neatly removed the tumour from this bloodbath with one nurse assisting me, but unfortunately, one pair of forceps didn't make it out.
And I think we all make errors. I'd be very surprised. I'm very happy if there's anybody out there who thinks they've never made an error, but I think we all make errors, and they affect us.
They damage our confidence. They can damage the client's confidence in us, they, everybody in the practise, feels very down when, when, when errors and when things go wrong, when they affect, especially when they affect patient care. So trying to, reduce the possibility of errors is what we're going to try and talk about.
So human errors. So on that night when I made that human error that particular error. I was tired.
I was stressed. It was, the, as I say, there was massive haemorrhage going on, . There was just me and the nurse.
We did, we did, I think we did communicate well, but it was a complex problem, and it was an emergency scenario when often things do start to go wrong. So sort of things that happen with human errors is that we miss out steps in a procedure. That the problems are very complex and we get distracted, that we maybe sometimes have a lack of knowledge, we maybe don't know exactly, you know, we can start something and, and, and then we don't know exactly where we're going with it.
We're often tired, often stressed in a busy practise, and sometimes pressure from the owners as well. Those can all be factors which can contribute to human errors. I'm not going to talk massively about human errors tonight because I think human errors are something that we can never prevent, but we can put systems in place, as I say, to reduce them.
So system failures are. When Teams aren't working together, we maybe haven't got sufficient. Just aren't enough people to deal with the situation when you're rushed, and when are you not rushed, to be honest, in, in general practise.
So when there's time pressures when you're rushed, and then when there's no systems of work, no guidelines, no checklists. So looking back on my error, if we'd had checklists, if we counted out, the, the, the hemostats, forceps, and counted them in again. We could have prevented that error.
A system of work could have prevented that error, as it was because the problem was much more severe than we expected it to be when we started. We started with a set amount of forceps, which we knew, and then I was asking for more and more, and the nurse was opening more and more, and in the end, we weren't sure how many we had. So they weren't counted out.
So, I get, you know, there could have been systems of work that could have helped to prevent that error. Luckily, It was an error which I, it became apparent much later that, and the dog had other problems, and I was completely honest with the owner and told what happened, and they were incredibly understanding, and I think that's the other important thing with errors is that we need to be honest and open about them. Oh, here's a, here's your picture for Easter.
Here's some Easter bunnies for you to get you in the mood for chocolate. So communication failures are the other main cause. So we have human errors, system failures, and communication failures.
Communication failures can happen much more often when you've got teams that change often, when, and in veinary practises in the old days, there used to be quite small teams, and we usually worked with the same teams all the time. But these days, perhaps it's much bigger teams can change, with, with the current scenario of recruitment problems, you could have a lot of locums. So you may not always be working with people you used to working with you have temporary team members.
And the other thing is if you don't have an open practise culture where people are afraid to say things and afraid to speak up when, when an error happens or is about to happen, that can, that can be a factor in the, in the whole scenario. So there are 3 things, the human errors, the system failures, and the communication failures. And the system failures and the communication failures, I think go together quite a lot because some of the system tools that we use are to encourage us to communicate.
So I hope that you will have read or seen this article. We need to talk about error, which was in the vet record. It was from Catherine Oxterby, who, who now works for VDS and did a great webinar about human error the other day.
And it was talked about the causes of error, and again, she talks about system failures and active failures, lack of ability, etc. And then these figures are quite interesting. These were from VDS claims figures, and breaking down what the causes of errors were, and they've got the first figure is the percentage in veterinary practise, and the figure in brackets is the percentage in, in human medicine.
So we've got surgery right up there at the top. So my error was in that compartment. Medical treatment.
Diagnostic errors, errors to do with parttrition, and this was in large animal and small animal, advice errors and anaesthesia errors. And I must admit, personally, I was quite surprised that anaesthesia only came quite low at 2% and the same in, in the human field. I thought that might be higher.
I thought there's a quite interesting, Areas for thought here. So what can we try and do to reduce errors? Well, we can make sure that we are communicating as well as we can in our practises.
We can Try and have an open culture, we must try and have an open no blame culture where people feel that they can speak up, when they think things might be happening or when they think there's a potential for errors to happen and they're not going to be slapped down by somebody else that they can speak up and, and say something. I mean, the number of times I've been, prevented from making errors by nurses, is, is multiple, so I think it's great that, you know, the whole team's involved. We can try and encourage teamwork, we can do, we can train, we can do communication training.
And then the other things we can do are looking at systems that we can use. So drawing up, looking at the evidence base, and then drawing up protocols, drawing up guidelines, checklists, and then once we've drawn them up, using them, actually using those protocols, guidelines and checklists regularly. So we get in the habit of using them and monitoring their use by auditing them.
And the other thing that's really important is that we report incidents that happen and report near misses. Near misses are absolute gold dust. Near misses are great because nothing has actually gone wrong.
So people are more likely to be really open and talk about them, and you can learn so much from near misses. So I would strongly recommend that whatever else you do or don't do, you keep a record of near misses in the practise, even if it's with a book, with a near miss book or whatever, and a lot of the near misses often are dispensing near misses, so that near miss book might might live in the dispensary maybe, but there can be other ones too, and, and just think about what might have happened and what systems you could change to make that less likely. So we can't prevent human error, but like I said, we can improve systems of work and, and improve communication, and this slide is just to remind me that I think practises.
Sent are quite happy to spend a lot of money. Now I'm sorry, this is the old BSAVA Congress programme, so we're coming up next week, but they spent a lot of money on sending their team to BSAVA or to London Vet Show or any other congress to spend a lot of money to get some really great CPD, which is right, and also to get their membership of Webinar vet and get great CPD. They're also more than happy to spend a to go around the exhibition at BSAVA or London Vet show.
And spend money on some lovely shiny new toys. Which we can all use, and that'll be great, and that's going to really improve care. But what practises seem to be less keen on doing is spending time, I know time is money, but it's time, essentially, on instituting systems of work, and systems of work, I'm hope I'll show you in a minute, can be as powerful ways of improving care as new information from CPD and as new shiny bits of kit that you'd get in practise.
Like I said before, it's really important to report errors and near misses, and it's really important that we do that. And if you look at, air safety, I like this little, little picture here. Yeah, the, guy crashes his plane, and the, and the other guy says to him, You're unlucky there.
I very nearly had the same thing happen to me in the same circumstances yesterday. So the other one says, Well, didn't you think of actually reporting it to the Air safety information management system? So that we all knew, then perhaps this wouldn't have happened today if somebody had reported it yesterday.
So that's from the RAF Safety Centre, and I think, you know, they've got, there's, there's a lot of safety culture we can learn from, from other settings. So, we, we should be open to learning about that. So Pilots don't just get in a plane, like we get in our car.
And just set off. Every plane, every, every different model of every, every plane has a checklist that goes with it, which is a massive checklists, and these aviation checklists are modified every time there's an incident or an accident or a near miss, no anything's reported. And the important thing is that they are read out.
So generally there's a pilot and a co-pilot, and one of them will read out the checklist, and the other one will do whatever. So it's check this, check that, and they talk to each other. I talked to one of my friends here who is a paramedic, because they often work with the same partner, but they also work with, with different team members.
And I asked him what they do at the beginning of a shift, and they do much a similar thing. They have a checklist of what should be in their ambulance. And they one of them reads it out or the other one checks, and they go us all go through that everything's there, and then they swap over and they go through that everything's working.
So those checklists are a communication tool, they are read out and they make those two people who maybe haven't worked together before. By the time they go to that checklist, they're a team. And they're ready for what's coming up.
They've prepared themselves mentally, they've communicated and they're working as a team. So I think that's a really important bit of checklist as well as the missing out complicated steps is the communication, that's also really important. We can learn from medicine.
Let's learn from human medicine as well. They've been doing this for longer than us. So one of the fathers of a checklists was Peter Provenost at John Hopkins Hospital.
And it was about central line infections, which they had an 11% . Right, in the hospital. So he drew up a checklist of what should happen.
Really simple, nice simple 5-step checklist. People, if you're putting on a central line, you should wash hands, clean the skin with chlorhexidine, drape up the patient, wear mask cap downs, gloves yourself, and put a sterile dressing over the site when it's done. At the start of this, he did an audit to find out what was happening.
And watch people doing it, that people, somebody just went around watching people do it. And 30% of the time, they didn't do one of those steps. They maybe didn't wash their hands, or they didn't wear the right PPE, or they didn't put a dressing over the site, etc.
So 30% of the time, one step was not followed. Then the important bit, the checklist was introduced, but the nurses were empowered, this is the important bit, to stop. The procedure, if one step was missed out, they could say even to one of the senior surgeons, no, you haven't cleaned the skin, stop.
So when they did that. Authorise nurses to use the checklist and to, to empower them to stop the doctors if the step wasn't followed. The infections went down from 11% right down to 0%.
So you can see how powerful a piece of paper can be. So, the other checklists that we can learn from from human medicine are the World Health organisation safe surgery checklists. So this was back in .
Round the 90s that the harm from surgery at that time, was, there was, there was massive harm from surgery, particularly in third world countries. And again, it's changing teams, etc. So the, the World Health organisation decided to introduce checklists.
Now, anybody who hasn't read Checklist Manifesto. But if I to go one day, I would strongly recommend it. It's such an easy book to read.
You could read it on your holidays. It's a great book. You won't put it down when you start it, and it's just about learning from medicine, learning from other cultures like aviation and buildings, and to institute checklists.
And he took go and he was a doctor from Boston, and he was involved in implementing these checklists in, third world countries initially. And the idea was that they would do confirmed checklist, they were, they were verbalised, they were read out. One member of the team would read them out at certain stages during the procedure.
So this is how the the human surgical safety checklist looked and still looks. So this is the first checklist was read out before induction of the anaesthesia. And so, well, first of all, everybody introduces themselves.
The first checklist is read out before the induction of anaesthesia. So Do, is this the right patient? Whi which is the site?
Is it marked? Have we checked the anaesthetic machine and, and any medication? Have we got the pulse ox or whatever monitor we're going to use?
And then looking at the notes, has the patient got an allergy? Do we think there might be a difficult airway, and do we think there's a risk of blood loss? So that checklist is there.
The important thing, as I say, is it's read out. If that with human nature, if you just look at that and go, yes, yes, yes, it's easy to just miss out steps and think, yeah, we got all that covered, that's fine. Just tick it all.
It's not ticking it that's important, it's reading it out that's important and making sure that one person confirms to the other that that's happening. The second part of the checklist was before skin incision with the nurse, the anaesthetist, and the surgeon. So this is where the team members introduce themselves by name and role.
Now, people feel silly doing that, and I understand why they feel silly doing that, especially if you work in regular teams. But I do think, especially in, in bigger practises where you don't work in regular teams, it's really important to do it. You're designating yourself, you're getting into the, into the, into the mode, you designate yourself, I'm the surgeon, I'm the, I'm the nurse, I'm the anaesthetist, whatever.
And then again check, double check this which patient it is, what procedure and where the incision's going to be. If antibiotic prophylaxis is appropriate, has that been given, and then the surgeon needs to think about. What might be the anything critical that might happen?
How long do you think this is going to take and what blood loss do you think there's going to be? Those questions are asked to the surgeon. Anaesthetist, are there any specific concerns about this patient?
And the nursing team, are the instruments sterile? Have we got, we got all the right kit? Anything we might need for the whole thing?
And have we got any imaging? And then the last checklist is read out before the patient leaves the operating theatre. Again, it's just confirming what's been done.
Instrument, sponge and needle counts. Like I say, that would have been useful in, in my example of mistake. Labelling any samples.
Whether there were any equipment problems to be addressed, I've always found that really, annoying when I had to practise when you'd say, can you get a suction and I go, it's not working. What do you mean it's not working? Oh, it wasn't working last week.
But nobody's done anything about it. So I think addressing those problems at the end and then key concerns for recovery and management of the patient. So that's very simple, it's a piece of paper and it's got 3 reasonably short checklists, and this can be modified to be used in in veterinary medicine and is being modified and being used in various practises now.
So this is, these are the results in 2009 in the pilot study of using that checklist. And this was in, this was in the third world countries, but then Ioane took this back to his hospital in Boston and Suggested they start using it there. And of course, his colleagues were like, well, we're surgeons, we don't need this, we're surgeons, we know what we're doing.
But he was, they were persuaded to use it and the nurses were empowered to read it out. And they've got great results there. So I think these results to me persuade me of how powerful a checklist is.
Deaths of patients fell by 47%. Complications fell by 36%. Infections down by 48%.
78% of the time, they said, the team members said it's help to prevent an error. They thought this could have happened, but we'd already asked that, so they thought in 78% of the time it could have prevented an error. And then this one I think is the most powerful.
93% of the team members involved said if they were a patient and they were having a procedure, they would want someone to use a checklist. No, I think that's really powerful data there and I think if you could go. And buy a piece of kit that would do that, that would reduce deaths by 47%, infections by 48%, you would do it, wouldn't you?
If you could, get a new drug in that would do that, you would do it. So why not take the time and effort to have systems of work and a piece of paper, which takes time and effort to introduce, but will have a powerful effect, and we'll get the communication going in your teams. So how would you introduce surgical checklist then?
First thing to do is to audit the complications first, that's benchmarking, that's to see what your rate of complications is before you even start, and that you don't have to do that, but it's really useful because then you can see an improvement. What you do need to do is involve the team. And it's no good just suddenly plunking this onto people and saying, oh, tomorrow we're going to start using a checklist.
It's got to involve the team, we've got to explain to them, show them the kind of figures we've just been talking about. It's good if a leader in the practise adopts it first and sticks to it and reads things out and makes themselves sound look silly, and does it consistently. Because that way, other people are going to follow, but there's got to be team training, there's got to be discussion.
People have got to be able to say, I'm worried about this because, or I think this will, slow us down, or whatever they think the problem is. There's got to be education. You can't just be introduced just like that.
And World Health organisation were aware of that, and they had a surgical safety checklist implementation tool, which you can still download from the World Health organisation website. And I would strongly recommend that if you're thinking of introducing a checklist, that you do do that, if you're not you're already using one. And, and plan it, plan, plan that you're going to introduce it, talk, first of all, have a talk with your team about why it might be useful, then have a talk about how you're going to use it and then do some training around it, and, and then introduced and then have a, have, have more talks about how people are finding it, or meetings about how they're finding it, .
And, and monitor that because you want to keep everybody on board. You don't want this to be, and, and when I talked to some people, when I did a talk on this a couple of years ago, I took some practises. Nurses mostly loved them.
Some vets were a little bit more reluctant. Some people told me things like, we use them, but not in emergencies, which to me seems that's exactly the time you should be using it because then you're stressed and rushing. So it's more likely you'll miss out a complex step.
You know, we just think it's, it's just one more thing to just tick the boxes. So like I said before, ticking the boxes is in a way the least important bit. You don't have to actually do it as long as every question is asked and answered.
So, what should your checklist be like then, any kind of checklist. The ideal checklist has to be short, simple, and evidence-based, and those check World Health organisation checklists are about as long as a checklist should be. If it starts getting longer, it starts becoming a protocol or, or a guideline, and that's not what we want, want, want a short, simple checklist, and it should be evidence-based.
So you should look at why you're asking the questions. It's not gonna work if it's too long, definitely not. If it's too complex.
If it's just dropped on people and not introduced properly. If you have too many checklists, you can have checklist overload. You can think, yeah, one checklist is great, so let's have loads more.
It's good to have some more, but you can have checklist overload. And the other thing is monitor its use. And the best way to monitor its use is to just audit and how many procedures a checklist is actually used.
You can first of all, just audit if it's used or not. You can do that retrospectively, looking back over records or by observation on the day or whatever. Then you can actually start auditing if people are actually ticking the boxes, you can actually start auditing how many of the questions actually get answered and ticked off.
But you need to, to monitor the use and then see, again, maybe do another audit as you did at your baseline to see if, if you've got improvement, see if you've got those figures of improvements on post-op complications, or anaesthetic complications. So, checklist could be useful in all sorts of different areas of the practise, not, not just in surgery. It can be very useful for, nurse triage, for, equipment checklists for procedures, cleaning checklists, surgery checklists for different procedures, to, to how to, to set up anaesthesia checklists, case handover checklist.
There's lots of potential areas where checklists can be useful, but it's not a good idea to try and introduce all these at one go. I would definitely do it stepwise. Choose the most important area first of all.
And get everybody on board with that before you start introducing loads more checklists. I think you've probably all seen the Association of Veterinary anaesthetists anaesthetic Safety Checklist, and that also comes with a booklet, booklet, sorry, which is an implementation manual, which is really important, the same as with the World Health organisation manual. It's the way to get it in there.
It's the same thing, prepare your teams, talk about it, introduce it, monitor how it's used, and that's, that's very useful, and I think you've probably all seen this and it's. They, they probably can, you can pick them up at conferences and things, and they're laminated, so they can be gone through and wiped off afterwards, so, and, and not kept. We, that's fine to do that.
Obviously, it's a little bit more difficult to, to, audit exactly what's been, been ticked off that way, but you can mark on your, on your anaesthetic chart, whether you, whether you've used one or not. And they all those things again, need reading out and going through. To make sure that that they're all happening and that one little step isn't missed out, like one little step, like the anaesthetic machine hasn't been checked, or like, we've got a leak or, we haven't got the, we haven't checked the cuff of the ET tube, all those kind of things.
So it's really important to, to, to, to do all those things to go through the check, full checklist. Another time when I think a checklist is really, really useful is case handover. Often case handover is, it can be during the day, but often it's from, night teams to day teams, and by definition, night teams are tired and also want to get home because they've been working for hours and hours.
Day teams have just arrived and have everything happening and, and people are telling them all sorts of things. So I think to have a, a, a, checklist, a case handover tool is Really useful. And this was a paper from Australia about an ISPAR case hand over to a human medicine, which I thought was really interesting.
They actually videoed case handovers, see how, how long they took and what information was actually transmitted. And then they started, got an actual structure for a checklist, and the structure was eyes, identity of the patient, so just the name of the patient. Than the situation, so what the problem or symptoms were and how stable the patient was.
Then the background, relevant past history and the date of the that the patient came in. Then the assessment and action. So what's the diagnosis and what treatment have we done so far?
And then the response and rationale, so. What investigations are underway and what's the plan going forward? They found that using this did not make the handover any shorter.
They still took as much time, but the quality of the information passed over was much better, because it's so easy to get a little bit diverted and start talking about. The owner said this or whatever happened, I get a little bit sidetracked, and not, and miss out some of those things. So I think a simple version based on something like this, a simple checklist for case handover, is a really useful thing to have, to, to all handovers, whether it be in the daytime or between day and night stuff.
And that's a useful paper if anybody wants to look at it. So, I've got a question for you now, because I want to see if there's anybody out there actually listening. So, does your practise currently use a surgical checklist?
We're talking about surgical checklist now. You may use other ones, but do you use something based on the safe surgery checklist? There are some veterinary versions of it out there now.
So I'd just like to know, am I preaching to the converted who all already use a checklist or not? Well, I think they are listening, Pam, because they were straight off the mark as soon as they launched that poll. So people are tuned in and listening.
So I'm just gonna give you 5 more seconds to, jot down your answers. Just click yes or no, quite straightforward. Does your practise currently Use a surgical checklist.
There's no right or wrong brand, so you're not gonna be beaten up if you say no, you're not currently using one. Please just be honest. I'm just interested, that's all.
And it'll be obviously good to then understand that after this, if you are then going to implement the surgical checklist once you've obviously watched this webinar. So I'll end the polling there. OK, quite interesting.
39% PA currently do, use the surgical checklist and so that means that 61% currently don't. OK, so about 3, just over 1/3 do. That's probably higher than the general veterinary population, I think.
So, by the fact that you're interested in listening to a not very sexy subject, like, implementing systems in the practise, probably your kind of practise that would do it, but still, that's, there's still 2/3 of you out there who might think about doing that, so that's great. So, that we've talked about checklists. Let's go on now.
To talk about protocols and guidelines. Obviously, you all know that I'm involved in practise standards, and we all know that, practise standards loves SOPs. So what are SOPs, standard operating procedures?
There's a definition of them here. They are methods to be followed for performance of designated operations, so that they're done efficiently, with the same outcome and with uniform performance, and avoiding miscommunications. And the risk of non-compliance and keeping with industry or legal requirements.
So, for instance, you probably have all got an SOP for the, which will cover controlled drugs, it'll cover storage, recording, who has access, what to do in the event of a discrepancy, all that everything to do with controlled drugs. Most of that is a legal requirement, and so that's, that's an SAP. Protocols, again, are sets of instructions for situations where you want to come to a known outcome, and they're great for training teams, they're great for inexperienced team members.
So again, it's for a situation where something's got to be done in a certain way. So dispensing medicines. Now, not all that is necessarily legal, but there's a way you do it in your practise, and there's that protocol.
You've got protocols for prescribing and you've got protocols for dispensing. You might have cleaning protocols. You should stick to a protocol.
Protocol is not something that you choose to, to not follow, it's something you should follow. Whereas a guideline, Clinical guidelines. Are not, are something that's there to guide and help people in practise to make good decisions.
They're not there as an alternative to your experience, they're to be used with it, used in conjunction with clinical experience. And we all know that if we have guidelines for how we're going to treat something, guidelines for how we're going to treat diabetes mellitus or how often we're gonna blood sample cats with diabetes mellitus or hyperthyroidism. There are going to be reasons in individual cases where we do not stick to the guidelines because of owner compliance, animal issues, cost, all sorts of things, but they're there to just guide us in the right direction, be developed.
And they should be developed by teams discussing things together by looking at the evidence base where it exists, but the problem we have in veterinary medicine is that sometimes there isn't the evidence base, but where it exists, looking at the evidence base. And then drawing up guidelines about what we think is the most appropriate way to deal with a certain clinical situation. Now, in the NHS, they have NICE, National Institute of Clinical Excellence, which provides lots of guidelines and protocols, and a lot of theirs are actually protocols for them.
We don't actually have vice in the veterinary world. So we tend to have to do these things more ourselves. At a practise level and have practise guidelines, although there can be some consensus guidelines.
There can be consensus guidelines of what have already been drawn up for us by, by, experts in the field, and can be used by practises. So for instance, ISFM have published some guidelines about how to diagnose and how to manage hypertension in cats, feline chronic kidney disease. Diabetes mellitus.
So there are some consensus guidelines out there, which can be either just used as they are, or adapted to your practises situation. Going back to the, national guidelines and things, as I say. In human medicine, they have these, these, these guidelines and protocols, but we actually at one of the evidence-based meetings, we had someone from NICE who told us that it costs a quarter of a million pounds to draw up each protocol, which I find very hard to To understand, I don't know how that can be, but obviously, we don't have those resources, but it's a matter of, of talking about these things and looking at the evidence base and trying to see how your practise is going to do things.
So why bother? Why bother with guidelines? Well, They're great for new, newly qualified vets are also great for locums because they can slot in better to how your practise does things.
I think quite a lot of locumming and usually you're you're lucky if they tell you how to use the computer system. So to have some guidelines of how things are done in the practise, I think is really useful to get a uniform approach. Which is, I mean, there's nothing annoys clients more than being given different advice on the same condition by 3 or 4 different vets.
For instance, with the, monitoring cats with diabetes, they might, one vet might tell them to come back in a month for blood sampling and one vet and the vet. Might say, well, if you come back now, you didn't need to come back for 2 months, and someone else might say, oh, no, we should have done it after 2 weeks. So having some consent, some guidelines can have a uniform approach.
It stops clients getting confused and clients being given convicting advice. Another reason you might develop a practise guideline would be after a significant event audit, so, which we're gonna talk about in a minute when something's gone wrong. So you may have, you may have had a rabbit anaesthetic death and decide, OK, we're gonna look at the evidence base, what's the best way to, to, anaesthetize rabbits, and then we're going to draw up a guideline for how we'd like rabbits to be anaesthetized in this practise.
And so, drawing up that guideline could be, a consequence of your significant event audit. But you might also have a guideline before you do an audit, so you're going to audit how often cats with renal failure have their blood pressure monitored. So you need a guideline first of all on how often, look at you look at the evidence base, look for a guideline of how often you, they should be monitored, and you can do some benchmarking of how often you do it in the practise and then do an audit.
So guidelines can go along with audit. So if you're going to draw up a practise guideline, it's really important to get the team together again, not to just impose it on people, to look at the evidence base, to have a meeting, and the great thing about this is the meeting looking at the evidence base and researching it all, having a meeting, that's all counts as CPD. Get the get the evidence together.
Draw, draw up a draught, circulate it, let everybody comment on it, have a meeting, everybody's gonna talk about their own way that they usually deal with things, which most people would think is the best way, but we'll discuss it as a team and come up with what we think is the best way overall. And so everybody's been consulted in the process. And it's then reviewed regularly and in practise standards in the new Awards, which are completely voluntary, obviously the scheme is voluntary, but the awards are are are an extra voluntary if you like.
In the awards, the in the patient consultation award, then we like practises to have therapeutic and diagnostic guidelines as points for having those, but we'd expect when the assessor goes along that they talk to team members and everyone, so the vets could all say what happened, how did you come up with this guideline? What happened? How, how is it drawn up?
And then do you use it? When do you use it? When don't you use it?
How useful do you find it? You know, talk to the whole team. So it's no good somebody just photocopying pages of a book and sticking them in a folder, in the consult room because it's got to be that the whole team's participated in this.
So why might you not want guidelines? Well, people really worry that they, they interfere with clinical freedom, but because they're guidelines. They're not protocols.
You don't absolutely have to follow them. They're a guide of the best way or what this practise thinks is the best way to deal with, with, with lame horses or whatever. So they don't have to interfere with clinical freedom, but that's one thing that team members might worry about.
The chap I was telling you about from NIE was telling us about the his, their protocols and how they cost so much to, to draw up. But you also said that the other worry is that what's happening now with some of the more newly qualified doctors is that they are so worried about ever deviate and say they do call them protocols, which makes it a bit more worrying, ever deviating from a protocol because they're worried that they'll be sued if they actually deviate from a protocol. And while if you've got a patient with just one condition, That's not too bad, but it, but it does mean they stop using, using their brain and thinking about the case and just use the protocol.
But if you start getting multi-morbidities, so in our case, if we get the old cat that's got renal failure and hyper and his hyperthyroid, then which protocol do you follow? Or which guideline would you follow? So, I mean, they, they are, as I, as we said at the beginning, to be used along with your experience and clinical expertise.
They're not, they're not a recipe. We're just doing, doing things exactly this way. But why were they good?
Well, they, they are good at at trying to make the team to be consistent. They're great for getting new team members and To go along with practise, the way practises do things, they're a great way of getting the team involved in evidence-based medicine where it exists and actually applying that in practise. They can be used to be audited to measure what you do, because if you don't measure what you do, how can you know exactly what you're doing?
If you don't measure it, you can't know how well you're doing. And clinical audit is a way of measuring our clinical effectiveness, how effective our, our, treatments and interventions are. And very importantly, they can help to reduce errors.
And if you reduce errors, you protect our patients, obviously, you help the clients and you protect practise team members because it's very, very, long, stressful procedure when you have complaints, either, either, people trying to sue you or have complaints to the college, it's a long stressful procedure. So anything you can do to reduce errors is going to reduce stress to practise team members. And how would you monitor?
So you've got these guidelines or protocols or checklists now in the practise, and how you're going to monitor, like I said, clinical audit is a way of monitoring, of measuring how our, our clinical efficiency, how, how efficient are our treatments are. So just a little. Tiny bit about clinical audit.
So we have outcome audits. They evaluate the results of care. So, benchmarking the, the, post-op complications or measuring anaesthetic deaths, there would be outcome orders or measuring the result of a certain procedure for cruciate repair or left display ama up in cattle.
Those are the outcome audits. They measure the outcome of something. Process audits, measure the way care is delivered, so they measure how protocols or guidelines or checklists are complied with.
Structural audits just measure what you've got available, so facilities and equipment, so like, what large animal vets might have in the boot of their car, or what you've got available if you're going to start a new procedure, what bits of kit you're going to need. And significant event audits, audit the result of one incident, from beginning to end. So look at what happened.
So process audits and significant event audits are both good ways of monitoring the systems of work we're putting in place. So here's an example of a of a process audit. Our pro our protocol should be evidence-based, and we want to find out if we're not following them, why we're not following them.
So let's say a process audit looks at how we follow a protocol or a guideline. So it could be with how we follow a guideline. So that should say guideline.
I beg your pardon, where it says blood compliance with blood sample protocol, it would be, will be a guideline for monitoring Cushing's or compliance with the dispensing protocol, or, a guideline on how often we, we would blood sample, hyperthyroid cats. So we've got our guideline or our protocol and we're going to monitor how, how efficiently we're using it. So here's an actual example.
So we're going to use a protocol here and that is That all repeat prescriptions, POMV medicines must be authorised by a vet. Rich told you at the beginning that I am very interested in medicine, so I've got medicines example here. So that's, that's, that's legal.
All repeat prescriptions must be authorised by a vet for POMV medicines. They could be authorised in advance prospectively, by the vet putting on the notes this dog can have me to come for 3 months. Or they can be authorised at the time.
By writing in a book, when, when the person rings up for someone to come, the receptionist writing it in a book or putting it on the computer list, and then I the fact either comes along and inside initials of the book, or they actually pushed up on the computer themselves. But the records need to show an audit trail. So they either need to show it's been properly authorised, or they need to show that a book that the vets initialled, or they need to show on the computer that either it went through on the vet's initials, or on that, where it's gone through, somebody's put OKed by PM whoever the vet is.
So the standard here, so the target or the standard, which in, in clinical audit, we need a target or a standard, and here that it should be 100% because this is a legal thing, this is what we should be doing. So this practise, we're looking how they were doing it, and they, so they looked back and did a retrospective audit, they got out the records and looked back over a 3 month period at repeat prescriptions for POMV medicines or POMV medicines. And this is the results they got.
68% were authorised, 23% in advance by putting the note on, can have this for 3 months. 45% authorised on the day. But this meant that 3, 32%, obviously, by definition, were not authorised.
So then the next step is to look into why that's happening. Why hasn't it been authorised? So, in this case, they, when they talk to the team, Everyone told them that they weren't really sure what how they should be doing this and they they did have a dispensing protocol, but it was very confusing.
So therefore, it wasn't always followed. They were rushing like we all are. And sometimes the vets were doing it, but they weren't marking the records, so there's nothing there to prove.
So the action then was to revise and and rewrite the dispensing protocol, make it clearer and more understandable, and then train the team to use it so that everybody knew how it works, so everybody, receptionists, nurses, vets, everybody knew how dispensing protocol worked. Then the key is to wait, and I think you probably wait a couple of months at least for this system to bed in. And then do the same thing again, audit again.
So I haven't got any re-audit results, but hopefully, re-audit results, those figures, the 68%, I would hope, have gone up to, something in the sort of 80s or 90s, and to aim towards our target of 100%. So that's the way to do a process audit of a protocol. I think process audit is amazingly useful in veterinary practise.
It's much easier, quicker to do the outcome audit, and can give you information that you can make changes straight away. So you could audit anaesthetic consent forms. So you could choose whatever criteria you want to.
You could say that every form should have the name of the procedure, a contact phone number for the owner, probably not going to be there, but never mind. An estimate and the signature. So you could choose those four things.
Then again, you could retrospectively look back over the last 3 months or 6 months and mark how many of them had those things. So you might come up with, well, 90% have the correct name of the procedure, and 80% of the phone number, but only 50% of an estimate, and hopefully 100% of a signature. So you can say, OK, we want people to have an estimate, so we're going to do some team training to remind everybody that there must be an estimate on consent forms and to remind people that these things are important, and then leave it, get your, do some team training and audit again.
Same thing, you could do it with anaesthetic monitoring sheets. You could choose what you want from that, what you want to check. It could be the details of pre-med, it could be the induction agent, could be how often you put the entries in.
Pain scoring sheets, again, could be, how soon it's done after a procedure and how often after that. Surgical checklist, like I said before, either that you use it or don't use it, or how, how it's filled in. And those audits you can do quite quickly, you can make changes quite quickly.
You can do them again, repeat them and see an improvement quite quickly, and everybody can see how they're making a difference. Nurses love doing it, and if you get your nurses involved in doing this, they'll come up with all sorts of ideas, and I think it's a really useful thing to do. So, while I get my breath back, another question.
Does your practise carry out process audits of how guidelines and protocols and checklists if you use them are implemented? Do you do any process audits of how you actually use your guidelines and protocols? I said before, there's no right, wrong or right answer, just I'm just interested to know how many people are doing this.
Fantastic. OK, I'll give it another 10 seconds for those who are still, pondering whether they do or they don't. As Pam says, there's no right or wrong, it's just out of interest to see what people's current practises are.
Mm OK. I'll end the polling now. And I see here that 24% currently do carry out the process of audits and 76% don't.
OK, so that's a bit less than than use the checklist then. So that's interesting because I think it's such a simple and easy thing to do. It's something you could go back to practise and do tomorrow.
And I just think you get some really good information. OK, we're getting towards the end of the time, so my, last little section is about significant event audits. A significant event and the definition from GP practise, human GP practise is an event thought by anyone in the team to be significant.
It's not necessarily a critical event, like an anaesthetic death. It's just something that affects the care of patients or the way the practise runs. It is more of a qualitative thing.
There's no numbers involved in this. It's, it's about looking at one event from start to finish and seeing what happened and how we could possibly change it if we need to, but it still needs a framework, a structured framework to do it regularly. So significant events can be serious, like I say, like the anaesthetic death.
They can be things like, lab samples going astray or lab report, lab results not being reported to clients. They can be things like the dreaded wrong cremation. They can follow client complaints.
They're great, it's a great way to use near misses, and they can be positive as well, like, you know, having a successful CPCR when you thought it was not going to be and things like that. So. They don't always have to be negative things, but you can analyse what happened and what you can learn from it.
I think it's a great way to get everybody involved with clinical governance, with evidence-based medicine, and about learning and, and everybody trying to improve patient care, and especially if it's after something negative when people are feeling a bit down, it's a good way to look at what's happened and try and get something positive from it, and therefore, it can really improve teamwork, communication with the team, and morale in the team. I think that those are really important things. And it is a whole practise team.
I strongly recommend if you do this, that you get everybody, receptionists, nursing assistants, nurses, vets, the whole team, because you get different perspective as vets, we can sometimes just get, be looking at clinical detail, whereas we get the whole team in, people look at the bigger picture more easily. So how are you gonna do it? Keep a log of significant events, include those near misses, get the information together, write a timeline of what happened, collect together stuff like records and consent forms and monitoring sheets and or complaint letters or anything, and then ask the individuals involved to tell their story of what happened.
So we've got the information. Then you have a meeting. The really important thing here is this meeting is not about blaming individuals at all.
It's about improving systems of work. This is all about improving systems of work. It's not about blaming people.
So this meeting has got to be open, fair, no blame meeting. Somebody needs to be in charge to make sure it stays like that and doesn't veer off into any of these other things. And it's a good idea to keep some action points from the meeting.
So you're going to analyse the incident. You're going to look at what happened, why it happened, the main reason and any underlying reasons, the main reason could be somebody forgot, but why do they forget what else is going on? What have you learned and what needs to change?
That's the basis of it. And when it comes to looking at what happened. Look at the root causes.
Don't just be like whatever this route the the the conventional approach route, don't just go, oh this happened and it was because of this. You've got to look at everything, there's lots and lots of systems and things might be involved, it might be involved in, in people and systems and everything, so look at the whole thing. The other great thing about root cause analysis is, in my opinion, it's like being a toddler again because you can just keep saying why.
So, in my little example, the owner came in to get the results of a lab test, and they went there. Why? Because, it wasn't in the lab log.
Why? Well, it was never sent away. Why wasn't it sent away?
Well, it was thrown away. Why was it thrown away? It was a, the nurse and vet both forgot at the end of the op, it was supposed to be going away.
Why? Well, it was a really complex op. It didn't go very well.
We were all stressed and it was a really busy day, and we just forgot. So it might be just forgot at the end, but there were all sorts of other factors. So you might think, OK, what would be the sort of action then?
Well, maybe, if we had a lab blog, which actually recorded when things, things went in it and when we got results back, and in this case, it never actually went in there, so that probably wouldn't have helped, but in general it would remind us, and surgical checklist. So in the surgical checklist at the end, any samples, let's label them, . Yeah, actually asked out loud, it's anything for pathology samples, so, but that's what root cause analysis is.
It's about keeping on asking why and trying to get down to the root of what actually happened, rather than just assuming that something happened because somebody forgot. Another way of showing this is in fish bone diagrams, and this comes from, one of the ones they have at, RCBS Knowledge. So we're thinking about clients waiting for a long time, what's involved, it can be people, can be not enough staff on that day, people off and people can patient clients coming in who, have not got appointments.
It can be equipment or something wrong with the computer that day. It can be the environment that they aren't enough consult rooms, so everybody's waiting. There's not enough parking, .
It could be things like the methods, so, so the, the files are disorganised, it's taking ages to register people at reception. Nobody knows the processes, the, the, the appointment system's not very good. So that's another way of analysing things into methods, people, environment, equipment.
Whatever you do, look for the root causes, that's the important thing. Look at what's actually happened. And then the results of looking at that might be think, OK, we need some training here guys, so we need some CPD.
We need some guidelines and protocols, or we've got some guidelines and protocols, but they're a bit confusing, so we, we need to change them. We might do an audit in the future. And we need to review the changes.
It's a good idea to write up these significant events, and this is a template I quite like of writing it up, which basically is quite simple, it just breaks it down to what happened, why, looking at human system and patient factors that we've talked about. What people learned from it, and what, what you're going to change, what has been changed, then a date when you're going to review it, cause obviously you got to review change and maybe you've maybe drawn up some new protocols or changed the protocols you have. So then let's do an audit to see if you're actually following those protocols, and then review it after 3 months or 6 months and see whether the changes have been effective or whether you need to make any other changes or do another process audit.
So it's good to write the things up because then you've got some structure rather than just, it's great to discuss them, but it's good to write them up and have some structure too. So just to finish off. Or just think about an actual near miss.
So Mr. Smith, who's very fit and healthy, he's 82, but he's very fit, it's a bit arthritic. He's got Fred, who's this old cat, who's a bit of a monkey, and, it's always fighting.
It's Fred's always in with cat bites. He came in, and the vet who was on that day, prescribed some and refloxacin tablets for for Fred. And the new student reinary nurse who'd only started that week, she was her first week in the practise.
She was in the put in the dispensary, and she put at the table tablets, according to the instructions on the label that was produced. Mr. Smith gets to reception.
Mr. Smith's regular, and he knows Denise, who's been working there for 20 years, worth a weight in gold, she knows everybody. She starts chatting to Mr.
Smith. Mr. Smith said, Oh God, he's given me some tablets for Fred.
Fred's a bit of a beggar. I don't think I'll get these tablets down, Fred. He scratches me to bits when I try.
And Denise, before she handed the tablets over, I had a look, and they were 50 mg tablets, and she's thinking, Fred's a very scrawny little cat. And so she went, just hang on a minute, Mr. Smith, I'll just have a word with the vet.
So she went back to see the vet and said, you know, basically, Mr. Smith can't give Fred these tablets. And anyway, are these the right tablets?
And he went, oh God, no, that's not the right thing. It should have been 15 mgs. I'll get him back in and, we'll give him a long-acting antibiotic injection and see him back in 48 hours.
So it was a near miss. Nothing went wrong, but potentially it could have gone wrong. And if you think that's a bit far-fetched, I have known of, cases where 150 milligramme tablets have been able to be got down a cat with drastic consequences when with them, they only getting very scratched in the process as well.
So this practise, discuss this. So a meeting, they were looking at why it happened. It was busy.
They were rushing. The, the new student veinary nurse, I only just started that week. She hadn't had any in-house training.
She didn't know anything about the protocol. She was just dumped into the dispensary. The vet was saying that the drop-down box on the computer was, was very difficult.
It was easy to confuse things. And, but the, the nurse had Wasn't sure that the tablets were right, but she had asked the vet earlier about something else, and he'd been a bit grumpy with her that morning. He was obviously in a bit of a bad mood.
So, and she didn't really know him because she was new, so she didn't like to say anything. So that's the factors that that might happen. And I think all those things can happen quite easily in practise.
So this practise, after had their meeting and discussed it all, decided that yes, they did need some change in protocols, they did need to have a better dispensing protocol, and more importantly, they need to to train their team to actually use it. It's like having a protocol, but using it is the important thing. They instituted a double checking system and double initialling system, which isn't a legal requirement, which is a good idea.
They thought about guidelines for use of antimicrobials and maybe some CPD on that because napflox is probably will almost certainly not the best first line antibiotic to use if a cat bite. Those are all the things that came out of it, some communication training, maybe because, you know, should, should the guy have been given tablets when he couldn't give them Dany's cat, was he asked the right questions? Then they decided once they had their dispensing protocol, then you tweak the dispensing protocol in place and they train their team, they would actually audit if they were using it.
And the other factor here is they try to have a look at practise culture. That's the hardest thing, but to try and get an open culture where it's a flat hierarchy, and anybody can speak up and say. And it's safer if people can.
If anyone can speak up and say, I'm not sure if this is actually right, without worrying about being, being, told off. OK, so that's, that was a significant event audit, and I hope that some of you are doing those, and I didn't put a question about that, but I hope you are, and I hope you're finding benefit from them. And then just, dispensing the also having physical systems can be useful as well.
So with, with that, one example I just gave, when I talked about that at the dispensing course, one of the delegates said that one way in the NHS that they do, if they've got 3 different sizes of the same medication, instead of putting them across the shelf horizontally, they'll put them vertically, with the big the biggest size at the top, and then the next and the next underneath each other, then that's less likely to make a mistake. This, I don't know if anybody's seen one of these is an, is an automatic dispensary. Type in here the medicine that you want to just prescribe, say, say, amoxicillin or something.
Then the little door opens just where that is, just there it is. The light comes on, little door opens, get that medicine out. Dispense it, put it back, it automatically to stop control, but it also, whatever you've typed in, is, is, is the door that opens, and it also has, fingerprint control for, controlled drugs.
So maybe that's the future. Maybe we'll have physical things in the future, and slightly different, but this practise had loads of trouble with getting people to. Getting vets to get off licence consent for unauthorised medicines.
So they took all the human medicines, and wait, these are the normal shelves here, everything else on, but they took the POMs that were POMVs and put them on the shelves and red edging, all the POMs are on here. And in here are the forms, the, consent forms for the off licence medicines. You take one of these, you use one of those.
So having physical systems is also really helpful to, to try and prevent errors. And I'm sure as time goes on, there will be more and more physical systems that we can use. Some of you might have, might know that VDS are launching an online reporting system, which would be great for collecting data.
It's an app, where you can report where they have, have had, errors, and I think it'll give us some great data about what the errors are in the profession, and it can be really useful, and that's what that Catherine Oxterby is doing, doing at VDS. But it's still necessary, I think for individual practises to discuss their own significant events locally and make their own local changes, you can't just give the data and forget about it. You've got to make your own local changes.
So to finish, What can we do to try and reduce errors or to try not to do the same things again, have that open culture, that flat hierarchy, think about complaints, use them as useful as a useful tool, not as a, an irritation. Think about errors and mistakes. Try and look at the bigger picture, so look at the non-medical factors as well as the, as the clinical factors, look at other things that are involved.
Have some good systems of work, implement them, actually use your checklist, guidelines and protocols, and then audit how you're using them. And move from, if you are practises that do have blame culture, move away from blame culture. This is nothing about blame culture.
It, it happens to everybody, and it's great. We need to discuss them because it's bad for our mental health to hide these things and not discuss them. We need to discuss them.
We need to get them out in the open, move from blame culture to quality improvement. And RCBS Knowledge have a quality improvement project. And they've got lots of really good resources, for practises who want to do audit or want to draw up protocols or guidelines, and I would recommend their website.
So those are free for any help that you might want with instituting these things, and there's a QI day at the SAVA next Friday. Anyway, thank you very much everybody for your attention, especially on this day when everybody's ready to start indulging in chocolate for Easter. So thanks very much.
Thank you very much for that, Pam, very informative and . I've, although we've run over slightly, I'm sure we've got a couple of minutes. It's all right, not a problem.
I'm sure it is all very important and, some very useful tips there. And, you know, it'd be interesting to know now for those people who answered them with the poll questions that they currently don't, have the surgical checklist and, you know, in terms of the procedures as well, whether that, this is then prompted them to go back into their practise and Start to implement some of those things that we you've discussed today. If you have got any questions, please do pop them in the Q&A box and we'll get to them then.
One question, Pam, you know, in terms of for people to, Carry out a significant event or a near miss. Is there a is there a like a standard template form that is accessible anywhere or is it the form I just showed before, if I can just go back, this one there we go, that is. I think it is now, but it certainly will be if it's not on the RCBS knowledge website as a part of the toolkit for significant event audit.
And I think that's just a nice simple one. You could do draw your own one, but I think that's a nice simple one. I think what would be really nice too is for practises to, to share, anonymized, obviously significant events because we all, you know, we can all learn from each other.
We don't have to make our own mistakes, we can learn from each other's mistakes too, can't we? Definitely, definitely. I think that this, Sue, put this question in quite early on, and then a couple of slides later, I think you addressed it slightly in terms of what some people's concerns were, but I'll just read out because I'll see if other people are thinking the same, but, she was saying her fear with SOPs and protocols, they could stop people actually thinking.
As it is at its basic level, it just ensures that people do whatever the procedure is consistently, but not necessarily accurately. So proofreading and testing these documents is vital. So I think, you know, in terms of that, I was looking at it from a.
It, it sort of sets what the baseline is, you know, what the minimum requirements are, and it's to encourage them, people to obviously, you know, exceed that, but it's to put in what the minimum accepted. Would you agree with that? But you know, it's to put that.
I would agree and and I totally understand what Sue's saying, and I think yes, following protocols mindlessly, especially if you don't understand why you're doing it. You know, for example, a practise standards an example, having a protocol that somebody monitors temperature of the fridge every day. Fine.
But that protocol also needs to say, what, what range should it be in and what do you do if it's not in that range. There's no point just doing it for the sake of doing it. It.
So I think that's important with the way you write the protocol, and protocols are a little bit more things where you do want people to do them in the set way like cleaning or or or or some of the dispensing ones, whereas guidelines are more about the clinical situation where It's absolutely. They're there as a help, but they're not, they're not an alternative to using your brain and thinking and thinking about what's appropriate for that particular case, taking into account the animal factors and the owner factors, and your experience and your expertise and what you can do in your practise. All those things have to come together with the guidelines, which is why you're never going to get 100% compliance with guidelines.
Fantastic. . We had a couple of, people just, typing in saying it's an excellent thought provoking presentation.
They've found it very useful. We've also got an anonymous person here saying they're starting a practise manager position in 2 weeks. And so it's been absolutely, vital for them.
And, you know, they, they hope they're gonna take a lot of this information in. They apparently, they, that, the laptop died for 4 minutes, but don't worry, whoever you are out there, this, is, is being recorded. And it will be available on our website.
We do say within 40 hours, but we, even at the webinar that we are kind enough to give our staff some time off. So, it'll probably be Tuesday now that it'll actually be up, on that, the recording will be up live on our web, on our website, sorry, so you can, once again, log in and review it again if you want to review it or if you want to share it as a lunch and learn with your practise, just to start that discussion, then you're more than welcome to do that. But it's a great, it is a great management tool, but I think you need to stress to your team as well, because the other thing people worry about some of these things is it can be a bit bigroy and a bit sort of trying to make people charge properly and things.
And it, you've got to stress to your team, it's about care. It's about, at the end of the day, it's about care of the animals and, and, and looking after our patients properly and, and getting the good results. Fantastic.
And do you know the the significant event form as well? Do you think It could be also used for non-clinical you know in terms of looking at that side of things as well. Definitely, I I I I mean that's the whole thing.
These are significant events, they're not critical events, when we used to think about critical events, we always thought about anaesthetic deaths or horrible post-op complications. These can be things that are really not particularly clinical. I mean, in one practise.
They discussed, the fact that a cat almost escaped being transported from the branch surgery to the main practise. That's not clinical at all. You know, and that's why I'm saying it's really good to have the whole team, because you get everybody's perspective on it.
So, and often, even clinical things often start with something non-clinical. They sometimes start in the waiting room with people waiting a long time. And somebody becoming, you know, is grumpy when they come in, and that's how complaints can start.
And there's often lots of factors involved. Maybe that some, you know, if, something you wanted wasn't there because, you know, it's someone else has put it in the wrong place when it when, when they run out of the drug order or whatever. So there's lots of factors, there's, there's, there's all sorts of factors involved.
But yeah, I'd definitely say things like, you know, the wrong. Cremation, which I've got another example that I often use for talks, which is the one cremation, which can happen very easily, if you haven't got systems somewhat labelling the bags and, and recording the request and and things like lab samples going astray. They're not really clinical, but they have can have massive effects, and they, and they can certainly cause complaints, which cause a lot of hassle and aggro for everybody.
Fantastic. I have a question here, Pam, I'm not sure that you know, See, you know, this webinar tonight, you can claim for CPD hours, but I think what the question is referring to is can the discussions in practise be logged as our our CVS CPD hours? Yes, absolutely.
I should have said that. I'm really glad. I'm really glad somebody asked that.
Definitely. When you go on the, if you go on the website, on the PDR website and do look at the dropdown box, there's a little bit that says clinical. Audit activity.
So all this clinical governance, quality improvement, that all comes under that. So having the meetings, discussing how you're going to draw up your guidelines, doing your audits or or implementing your guidelines, all that is claimable. So it's it's CPD as well.
So, and it's also, if you're in PI practise standards, it's also you record it and then you've got evidence to show the assessor. Of clinical governance, so it's a win all round, it's, it's evidence for clinical governance, it's CPD and it'll make your practise better. There you are, 3 wins in one, that's what we like.
Well, I think we'll leave it there for tonight, so all theses me do is say thank you very much to yourself, Pam, for that fantastic presentation. You know, the rest of you have a, if, if you're not working over the weekend, have a fantastic 4 day weekend for those of you who are working. All the best, you know, we really appreciate the, work you put in there and, we hope that you do get some time off in the near future.
But all the best. We don't want to keep you any further from your Easter eggs in a couple of days' time, and, we will see you on our webinar soon. Thank you very much.
Good night. Bye.