Good evening and welcome to the first in our 4 part series on anaesthesia hosted by Matt Gurney. Tonight's webinar is entitled Human Factors in anaesthesia, Safety and Risk. Before I hand over a little bit about Maths, Matt graduated from the University of Liverpool in 2003 and spent several years enjoying mixed practise before returning to Liverpool to undertake a residency in anaesthesia and analgesia.

Since 2009, he has worked at the North West Veterinary Specialists, a multi-disciplinary specialist hospital in Cheshire. Matt is a European veterinary specialist and an RCVS recognised specialist. So I'd say to kick off the first of our 4 part series, I'd like to hand over to Matt.

Thanks a lot, Matt. Hello and welcome to this webinar, the first one in series. This is Human Factors in anaesthesia, and we can talk about safety and risk.

So as a series overview, today we're gonna talk about human factors and safety. Next time, new drugs, new ideas on old drugs. Third session will be what should I be monitoring and we'll wind up the series with controversies in anaesthesia, so I look forward to working with you over the coming weeks.

It's just an overview tonight, we're gonna look at human factors, safety, and we'll talk a little bit about risk management as well. And just A Little bit of time to reflect. So when we talk about anaesthesia, what kind of risk discussion are you having with owners?

And I always think it's quite useful to have some information at your fingertips just to make those discussions a little bit easier. Bottom line is we mitigate against risk by having a plan. And what does that look like?

Well, one example for us would be with a high neurology case load dealing with seizure patients. If that patient seizures, we need a plan right there in order to intervene and stop those seizures. So any seizureing patient coming into the hospital has one of these stickers applied to their kennel sheet.

We've worked out the dose of diazepam as decided by our neurologist, this is what they would advise to give if that patient seizures. The nurse have got clear instructions, the interns, who to call, and those drugs are on the front of the, the dog's kennel, cat's kennel, and we know exactly how much we're giving, so when we're in a panic, we're not thinking, oh, hang on, what's the dose of us how much drugs do I need to be giving, how much is that in meals. So.

Education, planning helps us mitigate against risk in those situations. I quite like this definition of risk, this is a new scientist definition. Risk by definition entails uncertainty, so a good risk taker needs a good grasp of probability.

And certainly we're not being encouraged to take risks, but every day with our, our veterinary practise, not just our anaesthetic practise, we're taking good, we're taking risks, but through our education, we have a good grasp of probability in order to make those risk assessments. And these are 4 factors by which we tackle risk. We think ahead, we break down the challenges that we face, be it anaesthesia, surgery, medical decisions, we take control of the situation, but we also have a reflective culture whereby we learn from our mistakes.

And a little bit more detail on that, thinking ahead, CPD that's why you're here tonight. We think about teamwork, we plan our cases. In order to break down those challenges, we take a stepwise approach.

OK, maybe that patient's really sick and you're really stressed about the anaesthetic, but you're probably the responsible person that's got to take control and also do the surgery as well. So you've got a lot to be thinking about and we do really need a good team in order to get us through. So actually for the vets listening.

You're the one with the ultimate decision making responsibility that has to lead that team, but bottom line is you're not alone. And through good teamwork and proper planning, we take this stepwise approach. For overall success in our cases.

And when we can, we sit down, we do a little bit of audit work, we reflect, and we think, OK, how am I gonna do that better next time, or what education do do I and the team need in order to reduce the stress associated with this and reduce the risks that we're taking so we can do the best for our patients. I'm sure this is in everybody's minds as a, a rough number. These are the, the numbers that came out of the SEPSAF study back in 2008, the confidential inquiry into perioperative small animal fatalities.

And, OK, this was published in 2008. This data was collected going back now, probably 2000, 2001. So, yes, it's this is the the most up to-date numbers we have about mortality, dogs, cats, rabbits and other species listed in that paper as well.

This is free to access if you want to look at the results and steps of study. But just to give you an indication, when you're talking to clients about risk, we're looking at approximately 1 in 2000 fit and healthy dogs are gonna die under anaesthetic, and approximately half that for cats, 1 in 900. You look at rabbits, we get a little bit more serious about the, the risk entails with anaesthesia.

And you can see how markedly increased those risks are when we start to talk about our sick patients. You do get an overall number there, that's not really a number that I use quoting to clients, because you can see the big difference. So probably day to day, most of us are dealing with ASA, American Society of Anesthesiologists, patients 1 to 2, so fit and healthy patients.

So those are the ones that I have in my head that I will talk to clients and we'll make it clear that actually, if your pets, if we can make an assessment of your pet and they're sicker, then obviously the risk of anaesthesia increases. We can be a little bit more specific as well. SEPA pulled some more information out, which we'll look at.

But just as our first poll question, I hope everybody gets the answer right on this one. When do our patients die? When are most of our patients dying?

Is it pre-med stage induction, maintenance or recovery? OK, so I'll just launch the poll now. So I've launched the poll, so as Matt says, oh, sorry.

I've launched the wrong poll question there, my bad. There we go. I'll do that again.

So we just launched the poll question now. So when do our patients die? Is it pre-med, induction, maintenance or recovery?

So if you can just place your votes, please. Give you 10, 5 more seconds. And the polling there.

OK, and 100% say during recovery. OK, excellent, thank you. We won't label that.

No, that was very well covered by the SEPSA study, and it, it would appear that we've learned a lot of lessons from that. And these are the exact statistics associated with that. You can see actually for dogs, you're looking at 40% of problems occurring in the maintenance period, 47% in the post-op period.

I don't have an honest, well, we don't, we don't have up to date figures on how that has changed. I, I still think there is that emphasis on the post-op period as being key in all species, certainly. But I think that, again, this is useful.

We all know this information. Owners don't know this information. They think that their patient's gonna drop off the needle when we give them an anaesthetic.

And this is really important information for us to give them when we're discussing. And explaining how we're going to mitigate against that risk. Well, we're going to have someone watching the patient very closely in the post-op period for as long as they require that level of intervention.

And of course bitch Bay dog castrate may need less intervention than a brachycephalic during that procedure. Getting a bit more specific with SEPA when they looked at different body systems if you like, and sort of the root cause of the, the reasons for death. Specific but not particularly specific, cardiac, cardiovascular collapse, cardiac arrest, respiratory, airway obstruction, hyperventilation, APL valve left left closed, this you will see as a recurring theme throughout this presentation, we'll talk about that again.

Neuro uncontrolled seizures, renal, they weren't particularly specific with what the renal causes of death were. But the main comment was that these patients are dying post-op when they're not watched closely. So yes, we have mortality figures, but we don't know exactly why they're dying.

But we can look at certain factors in dogs and cats that we know from SEPA that do increase risk. So for our second poll question. What are the key factors in dogs that increase risk, how sick they are, specific drugs we use, degree of stabilisation pre GA or brachycephalics.

Which of these factors, and you can choose as many as you like from here. OK, so I've launched the poll question there. So what are the key factors in dogs that increase risk?

How sick they are, the specific drugs we use, degree of stabilisation pre-GA or braciopalix. Hello, is anyone out there? Can people see the er pole?

There we go, we're getting a couple of responses now. I was getting a bit worried then. Didn't think we were gonna have any responses.

I thought you'd have stumped them at the first hurdle. OK, just give 5 more seconds. OK, and the pole.

So I've got one here, 100%, what are the key factors in dogs that increase risk, how sick they are. Yep, sounds good. Obviously, how sick they are is linked to the degree of stabilisation pre-anesthetic as well.

We'll come and talk about brachycephalics. Specifically drugs we use, interesting, we would think, oh, actually it's all about the drugs, it's not all about the drugs, so that's obviously clear to everybody. These are the factors that do increase risks, so ASA status, how sick these patients are, how urgent the procedure is, generally, sick patients, we're trying to get them into theatre as soon as possible, so that's affecting the degree of stabilisation, you can see that coming in here.

Dogs older than 12 years old, they are at increased risk under anaesthesia. Again, great information to be giving to your owners. They're always asking you when the dogs 9, 10, are they at increased risk under anaesthesia?

Probably not until they're over 12. Brachycephalic definitely being a brachycephalic does increase your risk. Small dogs, probably because they're less easy to monitor potentially.

Pulse palpation's a little bit more difficult. They are small, so they get cold, so they're probably more likely to take longer to recover. Complexity and duration of procedure, you can see that both of these factors are likely to increase risk under an anaesthesia.

Mask inductions, now this may not be exactly related to the drugs, potentially more to the technique. Maybe because around that period of time, remember this is sort of '99, 200, 2001, people are probably thinking, oh, you're really sick. I'm worried about which drugs I'm gonna give you, so I'm just gonna mask in tubes.

So that could be a confounder to do with how sick those patients are. And halothane, I don't think we're using halothane anymore, certainly not in the UK so that's something that's a little bit historical, but . Something of note but nothing that we're going to worry too much about because we don't really use it anymore.

So let's look at cats, what are the key factors in cats? Increasing risk, temperament, are difficult cats at greater risk under anaesthesia? Is it specific drugs?

What about fluid therapy? What about complexity of the procedure? OK, I've launched the poll question again.

Ma's keeping me on my toes at the moment with these poll questions. So what are the key factors in cats that increase risk, is it temperament, specific drugs we use, fluid therapy, or complexity of the procedure? I'll just give you 5 more seconds to vote.

Mm OK. I'll in the pole in that. And we've 100% again, it's getting a common thing in this, complexity of the procedure, they're saying is the key factor in the cats in cats that increase risk.

OK, this is one of those where we could have chosen as many answers as we liked, so everybody's nearly right in choosing complexity of of procedures. One other factor in there that we, we will discuss, temperament isn't part of that list and specific drugs we use wasn't a factor, and we will come to fluid therapy. Cos I think it's worth talking about.

So increased risk, ASA status, obviously the sicker you are as a cat, the more likely you are to die under anaesthesia. Same as dogs, when we're trying to be getting these patients into surgery, getting on with this because there's some sort of underlying problem that's urgent, we're more likely to die. Age, over 12 years old, more likely to die.

Extremes of weight, this is quite interesting, so not only those small patients that are losing lots of heat and difficult to place IV catheters and intubate, we're also experiencing problems in the much bigger cats as well. So again, really useful information for those owners. Complexity duration, same as dogs.

Intubation, again an interesting one, possibly related to the fact that maybe probably true now, but also at the time of SEPSA probably sedating more cats or using a triple combination in more cats to do procedures rather than pre-med, induction, intubate, maintenance. And potentially it's the sicker cats that people are, using induction agents, maintenance agents, and intubating. So maybe that's a confounded because these patients are sicker.

Maybe it's something to do with the fact that laryngospasm plays a role there in problems at extubation in particular. So take her message here is yes we should be intubating cats, but we need to just be careful with how we intubate those cats. And I'd say a similar thing for fluid therapy as well.

Is it that we were given a fluid therapy to the sick cats? Or is it that we're not great at monitoring our fluid therapy in cats? If you think around the time this study was conducted, maybe not many people had fluid pumps, a few but sets being used, those cats going back to their kennels, all of a sudden you turn around and they've had half a litre of fluids, rapidly.

So the message here is. Give these cats fluids, give cats fluids under anaesthesia, but just be careful how you administer fluids. So we're certainly not saying don't intubate cats and don't provide fluid therapy.

You're saying, just be careful with it. So we've got a clear list of factors that increase risk in cats and dogs here. Just going back to that definition of risk, so we have an understanding of risk.

We know how to mitigate against risk. When we're talking to owners about risks of anaesthesia, part of whether they'll go ahead with the procedure depends on how good a risk taker they are as well. And part of that is how much they trust us and how much they believe in our education and our explanations.

As to how safe their pet's gonna be under anaesthesia, so it's not just us, it's the owner that we need to talk to risk to about risk, and we normally say yes, there is a risk associated with every anaesthetic, but that risk is really small, and then go on to talk about the numbers that we've already talked about. Then you can apply specifics to the condition of that patient. So there's real value in using an an ASA, the Americas Society of Anesthesiologists, classification for every patient, because you can see that clear divide between the one and twos, no organic disease, mild systemic disease, versus patients with disease that is affecting their function.

And if you're not already using anaesthetic records or you want an anaesthetic record that has this very accessible, you can download an anaesthetic record for free from the Association of Veterinary anaesthetists website. So that's risk, and we'll talk about checklists now. So, checklists are something that we use on a day to day basis, and I don't actually know how we function without a checklists, how we didn't miss things.

They've been around in the aviation and construction industries for several years, and we'll talk about the rollout of the World Health organisation surgical safety checklist. And now how these are integral to anaesthetic practise. So the airline one's designed by each manufacturer for every single aircraft type because there are so many specifics associated with that aircraft type.

Updated on a regular basis, they're simple and quick to complete. They have routine lists before routine takeoff, routine shutdown, and emergency lists. So let's say there's an error message from one of the engines during a flight, there'll be a checklist that that pilot goes through with the co-pilot in order to locate the source of that problem.

And of course the bottom of the list, OK, we can't solve that problem, we're gonna shut that engine down. Completed at set time points before takeoff, during an emergency, following landing. This is the really interesting part.

There are important rules associated with these checklists. So when the aircraft is below 10,000 ft, there's no non-essential cockpit communication. So, oh yeah, how was your weekend, what did you get up to?

We're not having that conversation below 10,000 ft. And I think we can all think of induction of anaesthesia when we're there, we're given the induction agent or we're about to intubate, somebody walks into the prep room, oh yeah, hi, how are you? How was your weekend?

It distracts you. Potentially, we're going to miss something, get, make a mistake. So I quite like that concept of, communication below 10,000 ft.

And we can think about that again at the end of anaesthesia. Making sure there's nobody bursting into the prep room when we're about to extubate that brachycephallic or that cat that might go into laryngo spasm or jump off the table. And the use of formal titles in the cockpit, so first name terms is how the pilots and the co-pilot are addressing one another in the cockpit.

Just so there's absolute clarity of communication. It's really important that those steps are omitted because every step really counts and that we perform the process in the correct order. The aim of course is to minimise human error because we are human and err is human.

And as you can see from this picture, somebody had a particularly bad day in that plane. And we'll talk about how that happened. So if our checklists are going to work, let's just step back and think about this slightly.

We need to work as a team. And there was this really interesting piece of work that Google did called Project Aristotle looking at teamwork. They stated that teams are highly interdependent and need one another to get work done, which we can instantly associate with from a veterinary perspective.

But of course, we don't all get on all the time. There may be people that don't quite fire well together. And unclear goals or communication can of course get in the way of what we're trying to achieve.

And our bottom line here is safety of that pet that we're dealing with. We need to understand each other. We know that poor teamwork in emergency departments accounts for up to 43% of errors.

That's massive, that's really, really big, isn't it? Oh, we made a mistake because we weren't functioning as a particularly good team. Those of us that work with the same people day in and day out are going to form the best teams.

Because we've gone through those processes of forming a team, the storming bit where we have to work out who's place is in the team, who does what, who, does what associated with every single procedure, the forming, storming, norming and performing, of forming teams. So in an ideal world. We will be performing as a highly functional unit every single time reducing error rate.

So I think it's just worth just stepping back and thinking about teamwork associated with patient safety because it does really make a difference and we can see from this work. And this, if you just Google Project Aristotle, you'll find the outcomes of that piece of work by Google. And the, the number one thing associated with teamwork that they found from this study was psychological safety.

And the example of that is the nurse in the operating theatre who feels safe in that team to put their hands up and go. Actually, this patient hasn't had an antibiotic or this patient has had the wrong drug, something's gone wrong. I'm putting my hand up and I'm saying that we have a problem here, rather than not saying anything and it leading to patient harm.

So just think about that. Component of psychological safety, so we all feel safe around one another, we can verbalise our concerns, have a discussion. We don't feel like we're gonna get shot down or blamed if something goes wrong, and our ultimate goal is the outcome and the long term safety of our patient.

Really, really interesting piece of work, really interesting to think about in the context of all of this. So what did happen here is pretty, it's a disaster, you look at this and you think well actually the nose wheeler the plane collapsed, that's what happened. What did happen is the nose wheel hit the wrong way first, and I'm sure most of us are familiar with how a plane lands, it lands on its back wheels first.

It is along the runway and then it touches down. In order for it to do that, the approach has to be a certain degree, the nose, the pitch has to be a certain number of degrees up so the nose is higher than the tail. What happened here, the pilot, co-pilot, the first officer.

The first officer was landing the plane. So in the cabin, bottom line, responsibility is with the captain. So at any point, the captain can take control, even if the the first officer, the co-pilots flying that plane, if the captain says I have control they have control of the plane.

And that's a really simple piece of communication. I have control. So just think about that, in the team that you're working in, if something's about to go wrong and you have already had this discussion, you and your team, something's going wrong, you go, I have control, you are the decision maker, everybody is listening to you.

But what happens in the circumstance, so. The captain knew that that co-pilot was coming in and the angulation wasn't quite right. What the captain should have done is said, I have control, they should have pulled the nose up, aborted the landing and gone around again.

This wouldn't have happened. Co-pilot was there, angulation was wrong. What did the captain say?

Captain said, put it down. And so the K pilots. Not being in charge, because ultimately the captain's in charge, without the psychological safety scope, actually that's wrong.

And it was actually almost too late as well by this time they've gone through that decision making process, he does exactly what she tells him to do. He puts it down. That's what happens to this plane.

That was I can't remember how many millions, if you, if you Google Southwest Airlines, collapse nose wheel, you can read the whole story, which is quite interesting how many millions of pounds that costs. I think they both lost their jobs as well. I think you probably would get sacked, wouldn't you, for crashing a million pounds aeroplane.

We'll come back to quite an interesting facts and when we talk about causes of error associated with this. Let's wind back to medicine. I'm sure some of you have read the Checklist Manifesto by Doctor Atul Gawande, and he's one of the leaders in the development of medical checklists, and he used the aviation and construction checklists to develop the World Health organisation safe surgery checklists under the banner of the Safe Surgery Save Lives.

Because there are 4 big killers in human surgery, infection. We've got to make sure these patients have had appropriate antibiotics at appropriate timing. Haemorrhage, are we expecting haemorrhage?

What do we do? Do we have a plan for when that patient starts bleeding? Unsafe anaesthesia, things like closed APL valves, has the patient's trachea actually being intubated.

Have we given the right drug by the right route at the right dose? And do we know what to do when our unexpected events happened and have we planned for them. So lots to think about here.

With this checklist, which there's a picture on the slide here, or if you Google World Health organisation surgical safety checklist, you can can have this as a reference. They had some pilot hospitals that implemented the checklist in 2008. It underwent a 3 month trial period.

During that period, major complications fell by 36%, and mortality was reduced by 47%. There are massive numbers for human healthcare, if you scale that up. Not only in the world, Europe, UK, we're talking about huge, huge intervention and patient safety here.

And surprise surprise, it was rolled out by the World Health organisation in 2009. It's split into three sections, so we've got before induction of anaesthesia, before skin incision, and then before the patient leaves the operating theatre. And in a couple of slides you'll see the one that we've developed at Northwest that is suitable for specifically designed for our situation.

So if you're going to develop a checklist, I'd encourage you to take this and work it out for your individual circumstances. We've got certain things on there kind of at the end. Oh yeah, we've got equipment problems as well to be addressed.

Has the patient had an antibiotic and has the patient had a non-steroidal just to make sure, do we know when we give you a non-steroidal things like that adapted to our situation. Do checklists make a difference? This slide has got lots of reasons why checklists make a difference.

What we're going to do is look at some of the veterinary studies that demonstrate that there is a clear advantage to using checklists. Like we say, we're all human and we are all, we all make mistakes. That is the biggest factor in any mistake, be it fatal, non-fatal, critical or non-critical.

And it can be a series of errors actually that lead to those events or culminate in something minor be becoming something critical. And time and time again, you read about checklists, people skip steps, even if they know them, and you'll see people reading out checklists without looking at the checklist because they think they know it. They're probably just recounting that from memory, not actually listening to what the the answers that people are giving and doing it properly.

So if we are using a checklist, we need to be quite religious about how we go through it. This is quite a nice study from the states from 2014 that shows that yes, checklists definitely make a difference. What they did in this study is they set about, set out to determine the incidence of patient safety events.

They then looked at interventions they could develop to get around those safety events. And then they went back in a second phase and determined the effectiveness of those interventions. The study was conducted over 211 month periods.

It was in a university teaching hospital, and they had 4100 cases, so a very respectable number of dogs and cats enrolled in those. And just a quick note, when we talk about critical versus non-critical, a critical event leads to patient harm and has a risk of fatality. A non-critical event, patient harm has been avoided, what we would consider a near miss.

These are the kind of things that through a morbidity and mortality process, we would be encouraged to document, so we can look at how those near misses happened and whether we could avoid them happening in the future. I just think, what was your last critical or non-critical event? We all have them happen on a week in, week out basis.

What should we be doing to mitigate against these? What steps should we be putting in place so these can't happen again? So with this study, what problems do you think they found?

What problems do you think you would find if you did an audit of your anaesthetic practise? I know one of the big things that came out in the SEPSA study, we talked about closed APL valves. We still see that as a problem in our, in our hospital, people check the anaesthetic machine every morning or before.

Opening the theatre. But people have a habit of closing valves to check the integrity of your breathing system and then not opening that valve again. Closed APR valve post machine check was one of the big things that they found in this study.

Esophageal intubation. Any of you that joined me for the Caography webinar will have heard me talk about using catography to document tracheal intubation where you have catography available. There are other techniques that we can use to document tracheal versus esophageal intubation, and we certainly should be doing this because we know that that's that's missed that near miss or or or that error mistake can lead to patient harm.

And in human medicine, it's one of the standards of care, post intubation, two people, the anaesthetist and the operating department practitioner have to confirm verbally that they have seen a catnograph trace on the cat graft to document tracheal intubation. An easy step in our situation is to palpate the neck. When we palpate the neck of the patient, we should feel one tube, which is the ET tube within the trachea.

We feel two tubes, that's the ET tube in the oesophagus and the Here. So get get used to practising that if you don't really do that's really, easy step. And that's what they did in this study, because in that hospital, they didn't have callography at every one of their stations.

So they looked for something that fitted their circumstances. The thing you can do is once the once you've intubated, you can have somebody close the valve, squeeze the bag whilst you listen to both sides of the chest, and you should hear normal breath sounds when someone squeezes the bag. That's the second way to document tracheal intubation.

And medication errors, there was a high incidence of medication errors in this study, so either wrong drug, wrong route, or wrong dose, wrong patient. And the interventions that they put in place. For each of these steps was a check box on the anaesthetic record that was ticked before induction to say that someone had checked the machine and then they'd opened the APL valve.

They had a lot of students performing the intubations, so naturally they're gonna miss the larynx and the trachea on some occasions. So after every single intubation, the tech working on that case checks the nag to by palpation to verify intubation. And to attempt to minimise the medication errors, they read aloud the name of that medication prior to administration.

What did they document in those 4100 cases in the first period, they had an incident rate of 3.6%. In the second period, you can see there.

Incidents have reduced by half, so 1.4%, and that was a statistically significant reduction. You might think that looks like a really low percentage, but even 30 dogs out of that 40 dogs and cats out of those 4000 patients, if those are critical events, then that's 30 pets who have lost their lives because of human error.

So certainly a very valid study, very useful information coming out of this. So what do we think, what percentage of anaesthesia deaths are associated with human error? OK.

So I've launched the poll question there. So as Matt says, what percentage of, sorry, what percentage of anaesthesia deaths are associated with human error? Do you think it's 5 to 10%, 20 to 25%, 50%, or 50 to 75%?

Just give a couple more seconds to answer that. Well, I think, definitely the vets are voting and thinking no, we don't do that, not, not, not much of that can be down to us, it's down to other factors and they're all going for 5 to 10%, Matt. 5 to 10%.

Yeah, I'm thinking it might be higher personally. Yeah, it's the, it's that big number. Percentage of anaesthesia deaths that are associated with human error is 55 to 77% of the is the range of numbers that we have from the literature.

So it's actually much, much higher, I think. Anaesthesia death, most of the problems associated with associated with anaesthesia death are human error. And when you read about the statistics, particularly in the states and the number of people that die each year because of human error is absolutely massive.

This is one of the studies here that you can read if you want more information, looking at mobility and anaesthesia. It's quite scary. When I think about planning an anaesthetic and thinking about risk factors, I'm thinking about factors associated with the patient, and we actually focus on the patient, don't we, and particularly their health status.

And we can see from step how important health status is. The ASA gradient that's looking purely at the health status of the pets, is not looking at anything else, so it's just one area of scoring risk. Other things we've got to think about are procedural factors.

Is there a specific risk associated with that procedure? Type of procedure we're doing, have we done it before? Is it a particularly long procedure?

What's the risk of blood loss associated with that? What's the risk of infection? You saw from that data from the World Health organisation, what are the big killers associated with these patients is not actually their health status in all circumstances, it's to do with that procedure.

Equipment factors, do we have a problem with availability of equipment? Do we make mistakes by knowing, oh actually that piece of equipment isn't available or it's broken, but I'm gonna carry on anyway. Are we better cancelling those procedures and coming back when we do have the equipment available?

And we've looked at the contribution of human factors and teamwork in our own experience and errors. So just think about all of those things when we're planning our anaesthetic and assessing our risk. There's a lot to consider in these procedures that we do every day.

And there's certainly a role for checklists here. So we're very familiar with doing quite. I guess if you think about a bitch they would be my, my main example where there's quite a high risk of bleeding, it's a procedure that we perform every day.

Lots of vets are very experienced at that and therefore that markedly decreases that risk. If you compare that to some of the procedures human searchers are doing compared with the the risk of bleeding, it's pretty high, isn't it? Really high.

Those human factors again comes back to teamwork and the importance of psychological safety, but then there are all these other factors as well. So can we depend on other team members to do the job we expect them to do on time, meeting those standards that we all want to work to? Does everyone in that team know exactly what they're doing?

So if we do have a liey during surgery, do we have blood in stock, do we have a blood donor available? Do we know how much, do we know who's going to calculate blood loss in that circumstance? Do we have a a standard operating procedure for dealing with that?

I don't think we can really question too much. Area 4 from this, the meaning work is personally important to team members. I think we all work in the veterinary sector because we care very much about animals and the outcome of them.

And I think that reflects in the impact that our work has on us as well. But what about when we do actually make mistakes, cos none of us want to make mistakes, but inevitably errors do happen. This is a definition of error which was I took from this paper from Catherine Oxerby at VDS in Nottingham.

Looking at error. So errors are the result of interactions between cognitive limitations of an individual and the system that overall influences their decision. So a couple of factors there that we're gonna look at cognitive limitations.

And the system And are we talking about lapses or mistakes, so two definitions here. A lapse is an absent-minded error of distraction. So going back to what we said about being below 10,000 ft, did we forget to do something because somebody distracted us?

Did we give that antibiotic a little bit too quickly IV because we were chatting? Did we mean to give everything that was in that syringe because we got distracted and we just gave it. Did we give the drug IV but we meant to give it subcutaneously.

These could be examples of lapses. But a mistake is the incorrect application of a previously learned solution. So we know how to do something, we know how we should do it, but for some reason, we didn't do it properly.

We just watched this video. This is the surgeon injecting local anaesthetic at the end of the procedure. We all know before you inject local anaesthetic, you should draw back to check you're not injecting IV.

But this It's just been administered without any drawing back. So I call that a mistake. The surgeon knows that you should draw back before you inject local anaesthetic, that's the previously learned solution, but it's being applied incorrectly.

Or if we're at the end of the procedure and the surgeon's busy talking to the nurse, if you've done the swab count, maybe it's a lapse, maybe it's an absentminded error of distraction. So what happened here? Was this a lapse, was an absentminded error of distraction?

The pilot, neither the pilot nor the co-pilot should have been distracted below 10,000 ft. Was it a mistake? The incorrect application of the previously learned solution.

It was definitely a mistake, wasn't it, because the pilot should have taken control from the co-pilot when she realised that the angle of approach was wrong, should have aborted and gone round again. Is that a cognitive limitation or was it a systems error? It was definitely a cognitive limitation.

Because that pilot's decision making was at fault. However, when you look a little bit further into this story and the backstory associated with this, you realise there was actually a systems error there. Because There was no psychological safety between these two people.

And if you think about pilot, co-pilot situation, then they're very rarely do you get the same pilot and the same co-pilot. So they may not form that team, that bond that you need to work very effectively together. They are a functioning unit.

That's why you need so many checklists in the aviation industry. What happened here was, there were several reports from junior pilots saying that they cannot work with this captain, and they, there were various roster solutions that people were ducking out of doing flights with this particular pilot that the airliner hadn't dealt with. So you can see that this is actually a systems error because the airline hadn't dealt with the behaviour of this captain.

And these co-pilots would be made to fly with a captain who they didn't necessarily trust. So what initially looked like a mistake due to cog cognitive limitation and she had quite a large systems component as well. So quite an interesting example looking at other industries beyond anaesthesia, how these things happen.

And what can we learn from the veterinary context? How can we create checklists to account for problems that we see? This information again from Catherine Ox to be looking at VDS errors.

2% of VDS reported errors are associated with anaesthesia where whereas 41% are associated with surgical errors. So when we're talking about these creating these checklists, I'll certainly incorporate anaesthesia and surgery together. On that surgical errors list, the big things are complications with bit space, retained surgical items, I guess most commonly swapped.

I'm not quite sure what else, people leaving abdomens, and haemorrhage. So again, one of those big killers there. So we should be designing our checklists for these procedures that we.

Take it for granted and we do in a very routine manner. But actually things can become so routine that we don't actually know when we've made an error. And retained surgical items, I think is a classic example of that.

Oh, no, we never did a sore count because we don't need to, or, or we just forgotten that day, or I was working with a locum nurse. Whereas if you have a checklist and the nurse monitoring the anaesthetic says to you, how many swabs have you got on that trolley before you start and you count the swabs out, then you're not going to be in this situation. And here's another example from Sweden, looking at reduction in surgical complications by using a safe surgical checklist.

You can see their checklist on the left hand side here. They looked at various factors, they based it on the World Health organisation checklist, obviously, and they saw a reduction from 17% down to 7% post-op complications from using a checklist over a period of time. So you've seen here some really good evidence that use of checklist does indeed improve patient safety.

The last study we're gonna look at is this study from Cambridge published this year. Again, large cases over 3000 cases, 5% error rates. That had potential for patient harm.

That's quite a high number, isn't it? 5%. When we look at those numbers associated with patient death.

9.8% were actually catastrophic errors. The num, those numbers are actually getting a lot higher than what we saw in the SEPSA study.

So you're talking about 1 in 100. In this Cases, 9.8%.

And of those errors that could have led to patient harm, approximately 90% impacted the patient somehow. Combination of individual factors, team factors, organisational factors. You've got your clear cognitive systems errors there, an example of the import importance of teamwork and psychological safety.

These are all really valid things to think about when we're designing checklists and looking at reducing the impact of error in our own clinics. So how do we move on from here? This is a statement that came from this editorial written by Liz Chan a couple of years ago.

To be most effective, these checklists should be adapted, put into the context of our own hospital situation and tailored to meet our individual needs. And that's exactly what we've done. But it's useful to have somewhere to start, and you can download this anaesthetic safety checklist from the Association of Veterinary anaesthetists website or you can speak to your Duro technical advisor, and they'll be able to provide you with some of these checklists.

And it's got those three stages that we saw in the WHO list, so pre-induction, pre-procedure, and recovery. On the back, you've got an an anaesthetic machine check. It's designed to be completed at set time points, documents improvement in patient safety.

It does come with a full booklet as well, where there's a lot more information about all of those steps. And if you look at the AVA website, you'll find further information about small animal anaesthesia and monitoring standards, for example. That's the checklist a little bit more detail on the reverse.

It's got recommended procedures, pre-procedure. It's got how to do the anaesthetic machine check. It's got a little bit of information about drugs and equipment that you might like available with a link to the AAC CPR algorithm there.

So this is a really useful place to start. What we found, this is ours on the bottom right hand side here, we have a checklist for anaesthesia and surgery, and then we have a checklist for anaesthesia and diagnostic procedures as well, because a lot of the things like if we done a swab count, it's not relevant if we're doing a checklist for a dog going into MRI. So part of the MRI checklist is, have we thought about how we're gonna keep this patient warm in the scanner and have we removed all metal from the patient.

It's not uncommon for dogs to be wheeled away from the anaesthetic station towards MRI still have their collar on, or ECG pads on their feet. So we don't want these patients to come to harm, so make checklists specific to your situation. Don't skip steps cos you will miss things.

Complete them at the appropriate time. This is where. It takes training as part of the whole team.

So we started ours, this was an anesthesia-driven initiative. We had a little bit of resistance from the surgeons to start with. Some surgeons, oh, you're slowing me down.

Oh, I just want to start da da da. Well, actually, you're the one that's going to be in trouble with VDS, the owner, whoever, if you haven't done the swap count and if we haven't done the shark count. Yes, initial resistance is a team effort, and we did look at specific risk areas, .

We've seen the evidence regarding APL valves, it's really high on that list there. It should be used to combine with critical incident reporting as well. So there's no point in doing all this if we don't collect information about how we can change our list, and we tend to review these every 6 months just to make sure that our checklists are appropriate with any changes going on in the hospital.

Because things like having building work done and changing the work flow around the hospital, or having new surgeons doing new procedures does do bring new challenges and new risks. So my advice would be that you implement using an anaesthesia safety checklist. I personally think you'll certainly realise how did we ever survive without this, and that is very much my feeling about Checklists now, and we've used Checklist probably for the past 3 years, I'd say.

Other things to think about are maths non-anesthesia, non-anesthesia technical skills. So, teamwork, communication, and what I like to think about is closed loop communication. So you ask a question and you get an answer, that is the answer you need to hear, not, oh yeah, maybe it's OK.

Has this patient had its antibiotic? Yes, this patient has had its antibiotic. It's a bit like the whole pilot, co-pilot situation, somebody's in control, the person that's in control receives the message that they were intended to receive.

Situational awareness, it obviously just makes us think about the teams we're working with, the different people we're working with everyday, the different procedures that we're doing every day, so every procedure is different, every situation is different. Leadership, obviously somebody needs to be in charge. We need to iron out those issues that we might have with who's the boss on a day to day basis.

You might be the owner of the practise. But actually, who's leading the team for that particular procedure, are you the primary surgeon, is the nurse in charge of running the day? I think we have this overall drive to maintain our knowledge.

And keep an awareness of our self limits. So by all means, do you go and look at some of that work that Liz Armitage Chan looks at with non-anesthesia technical skills because it's all very, very relevant to, to this very interesting area. I just put this slide in about analysing error errors because it's something that's very topical at the moment, so yes, we need to talk about error, but we should avoid blame, we should look at take a systems approach and looking at the real reasons why did this actually happen.

A classic example for us would be the dog that received hypertonic saline instead of normal saline. Somebody asks another colleague to go and get some saline. It's stored in exactly the same place as the, the, the normal saline person didn't check the bag.

Hung the bag, gave it to the dog, dog developed problems associated with a high sodium load. How have we changed that? The fluids now don't live anywhere near one another and, As soon as the hypertonic saline comes into the hospital, it gets a red label put on it.

It lives in a box that you have to open the box that's got a, a red label on the top that said this is hypertonic saline. Somebody else has to check when that drug, that drug because it is a fluid, it is a drug. When that's hung, it's that checking the, the medication before we administer it to a patient, not being too blase.

And certainly we've had that when we change fluid supplier, oh this bag looks exactly the same as this bag, we now need to develop a system in our hospital to make sure people don't go hanging saline instead of hormons. So I mean that's not a massive disaster, but the hypertonic versus normal saline is an absolute disaster to get wrong. So that concludes our discussion on human factors in anaesthesia.

You can see that humans play a huge role in all errors associated with anaesthesia. We talked about risk and talking to owners about risk and I think if we talk to owners and say, we will, we will naturally say well there is a risk associated with anaesthesia, but we will do everything we can to prevent that from happening. These are the tools that you need to do everything that you can, this is what it means to be doing everything we can, and that really starts with checklists.

OK, thank you very much for that, Matt. That was fantastic. I meant to say, if you did have any questions throughout, please do put them in the Q&A box.

We do, Matt has finished in good times. We do have a few minutes, to answer any questions you may have. A couple of things that sprung to mind from my point of view and listening, Matt, the first one, I see you said, you know, in terms of us, you know, for different procedures have different checklists, but how often should, you know, it's one of those things you write a checklist.

And then you, you know, you'd follow it, but how often should you then review it, as part of the course, even if you don't think anything significant has changed with the procedure, you know, such as the, saline bags, coming from a different manufacturer or being changed. But where you can't perceive anything, how often should you still review those checklists? Actually during the procedure, we've got those 3 different stages, so we're checking before induction of anaesthesia, then we've got a timeout before the surgeon starts on the surgical checklist and then after they finish, so we're reviewing all of those steps.

You could then argue, OK, if that patient's going back to its kennel, should we be doing another checklist several days down the line? Does this patient still need to be on fluids? Is this patient still on the correct fluids?

So you can kind of take checklists in any direction you wish. I, I guess with regards to updating them on a more periodic basis, I think if anything changes in the hospital, then you should update that, that checklist. So to, to just to take account of varying circumstances.

We've had quite a lot of things over the years that have changed, going from, for example, having a visiting MRI or CT scanner in the car park to having our own scanner in the hospital, brings different risks, different challenges. So if we're transporting patients down a ramp up a lift into a truck in the car park, how have we got strapped to make sure that they're not gonna fall off the table? It seems really basic, but actually, if you lose the patient because it falls off the table and it breaks something, then we're in a lot of trouble there.

So that's, I, I guess an example of how the circumstance can change and we should adapt. It's all about, it's all about safety and protecting our patients, protecting our staff as well. Well, that's it, isn't it?

It's making sure that, you know, if there is anything does go wrong, you can clearly demonstrate that the procedures were followed and, you know, it's, it's for the good of the staff as well as obviously the patient. The other thing, you know, the other thing that occurred to me and is, I used to work for the fire service, so it's something that I, I used to sit on in the health and safety meetings once a month. And one of the things that we used to report on was the near misses.

And sometimes I think over the time I realised that the near misses actually gave us greater learning outcomes than actually when some you know, serious incidents did happen because. You could look at it and go, whew, that was close. Anyway, let's carry on.

Or you can, what we should really do in my eyes is then stop and go, that was close. Fortunately, nothing significant happened. However, it's a good opportunity to pause, analyse why that near miss nearly happen, and then do that.

Would you concur with that? You're absolutely you're absolutely right. Nobody wants to be in that situation where we go, oh, actually, oh yeah, that happened last month, and we should have done this about it, so.

Yeah. So, it's, it's, so rather than just thinking that was close, actually, yeah, just sit down and do it. And I think, you know, for me, the final point was, obviously, doing it in a non-blame culture and actually allowing everyone to have input, you know, from the receptionist through to the, you know, the, the, the vet, the director, etc.

Because they may all come with slightly different angles on it and, you know, . I think we've seen previously with, you know, receptionists, especially when they're dealing with the front of house, they can pick up on certain things that maybe other people aren't privy to. So I think it's important that one, as say, everyone's ideas are listened to and they, everyone has the opportunity to input onto the checklist to ensure that all eventualities are covered.

I think that's, that's the biggest challenge I think we're going to see over the next couple of years is, is living the no blame culture, because we're encouraged to to adopt no blame culture, and it really comes back to that element of psychological safety. If people work in a practise and they feel blamed, then they're gonna leave the practise, that's a factor in retention. We all want to be doing a really good job.

We go, we want to go to work every day and do a really good job, and we, at the end of the day, we don't want to feel like, oh, something went wrong and everybody's blaming me. What are you gonna do? You're just gonna leave that practise.

So it's not really good for anyone. Professional development or mental state to be in that situation. So definitely.

And just the final bit, we haven't had any questions come through, so it must have been a comprehensive, and you've answered all the points, but the one last one, could you just, reiterate, where people can go to, I, I think you said Duro, provide, you know, some. Checklist templates. Is there a web address or how is the best, is there a website people can go to to download them as well?

Yeah, best best places to look on the Association of Veterinary anaesthetists website is AVA.eu.com and you can.

Download it on the left hand side, they've got, anaesthesia resources there, and you can download anaesthetic records, you can download the checklist, and you can download anaesthesia information there, and that's all for free. Brilliant. Well, that's fantastic.

Thank you very much for this evening, Matt. It's been most interesting. With the, as I say, this was the first in a series of 4, we will be obviously coming back to you with the 2nd 1.

I don't have the date at hand, but what we will be doing will be when we send out an email to confirm that the recording is now available on our website, which should be in the next 48 hours. We'll also let you know when the next, live webinar is going to be with Matt, and we look forward to seeing you all then. So thank you very much for joining us.

Thank you to my colleague Dawn, who's been supporting as well from a technical side. And I, wish you an enjoyable rest of the evening. Thank you very much.

Good night.