Hello, I'm Helen Silver McMahon, and I'm looking forward to talking to you today about tools and tips to improve patient safety in the emergency care setting. In this session, we're going to explore the evidence-based tips and tools to improve patient safety in the ultra adaptive veterinary emergency care setting. So that it's possible to implement effective strategies to prevent adverse events.
We are going to describe how to plan a good day using huddles and halt. We're going to explore how checklists can be used in the emergency care setting. We're going to consider some of the non-technical skills that we require, and we're going to explore how we can improve patient safety and team wellbeing through learning, through talking.
Before we can begin to look at the tools and tips that might make our care safer, we need to understand the environment we work in, and we need to understand the different approaches to safety. When we look at the safer strategies for real world model that was created by Rene Amalberti and Charles Vincent, we can see how complex veterinary healthcare is. In some approaches to safety, we have to be ultra adaptive.
We have to embrace risk and we have to put our priority to adaption strategies and recovery strategies. Within the wider world. Systems that might use this approach to safety include trauma centres, Himalayan mountaineering, and armed forces in wartime.
The second type of approach to safety is high reliability, where we manage risk, and we put priority towards procedures and adaption strategies. Examples of this might be scheduled surgery, firefighting, the drilling industry, or low risk anesthesiology. And the third type of approach to safety is the ultra safe approach.
This is where we avoid risk and we put priority towards prevention strategies. And spaces that use this type of approach include radiotherapy, nuclear industry, railways, and civil aviation. What you can begin to see is that veterinary systems don't fit into one of these particular box, but rather they move and adapt between the different approaches.
On the one hand, we have to be ultra adaptive when we have an emergency patient come to the surgery. And on the other hand, we need to be ultra safe when we're delivering chemotherapy or radiotherapy or practising radiography. And somewhere in the middle, we also have to be highly reliable.
We have to be able to deliver scheduled surgery and low risk anesthesiology and keep our patients safe. So what you can begin to understand is that the reality is in fact very messy. It's never a one boxer time approach, and we need to consider the steps we can put in place, not only to reduce error, but to make sure we perform as efficiently as possible.
We need to maximise patient safety and ensure that the wellness of each of our team members is also attended to. In this section, we will explore two of the key ingredients for ensuring a successful day in veterinary practise, briefings and breaks. Briefings have been shown to reduce the risk of adverse events occurring and improve efficiency and collaboration within teams.
As part of the briefing, teams should be encouraged to plan ahead for short breaks and prioritise those breaks when they come. So why are huddles or briefings so important? Well, we know that the Joint Commission of accreditation of Healthcare organisations describes communication error as the cause of 60 to 70% of preventable hospital deaths, and this has been echoed by research within the veterinary profession where we know that human error is the largest cause of adverse events and the majority occurs when we're distracted or under stress, and inadequate care or negligence is extremely rare.
How often do we consider anything except our patients when we're performing rounds, and how do we ensure that everybody on the team has a shared mental model? When we undertake proactive communication like patient safety briefings or rounds or huddles or shift changeovers, we need to take the opportunity to ask ourselves and our teams what's different about today. As well as considering each patiently individually, we need to consider the team and the challenges we may face.
And how we can make it safer. We need to consider the moments where a single error from a single person could lead to harm and what steps we can put in place to stop that happening. When we do that, we enter threat and error management.
When we perform a brief, we should address the following questions that were designed by Sign Up to safety. We need to make sure that we know who is on the team, and we need to make sure that everybody is introduced by first name. We need to know their responsibilities and their roles within the team.
We then need to go on to understand that everybody has the same goals and aims and objectives, and we need to create a plan of care for the day or the shift. We need to consider what staff members we have available through the shift, who's on holiday, who's sick. And how this might affect the shift.
We also need to make sure that workload is shared fairly among the team members and that we are aware of any resources, equipment, drugs or medications that may not be available. We need to be aware of the machinery or equipment that's been sent off to be serviced and any drugs that are on back order so we can plan around those things. We also need to consider for a moment what we can anticipate could go wrong and how we will mitigate against them.
One of the anticipated pushbacks in practise from performing briefings is lack of time. However, it has been found that surgical teams perceived that briefing and debriefing improved efficiency and more operations started on time and less were unexpectedly long. It was found that the pre-op briefing took less than 4 minutes to conduct and that time was paid back by increased efficiency throughout the day.
The clinical Human Factors Group gives us key guidance on how we should use briefings when we're working under pressure. We need to brief the whole team, even if it's rapid and short, and check the understanding of every member of the team. Not making assumptions about shared insights and knowledge.
Leaders should lead by being open and inclusive and ask questions first and lead second. And we should encourage the team to speak up. We should make sure there's a low authority gradient, which makes it easier for everybody on the team to raise concerns.
During briefings we should take the opportunity to plan our breaks. We'll know that within the veterinary profession we're superheroes without capes and if it ever comes to the choice between a sandwich and a poorly patient, the poorly patient is always going to win. But research done at St.
Guy's and St. Thomas's NHS Foundation Trust found that unless critically ill patients require our immediate attention, our patients are always served better by members of staff who have had appropriate periods of rest during their shifts. So it's important that we recognise though that whilst we want to look after the patients to the best of our abilities, by missing our breaks and becoming tired or hungry, we are actually not providing them with our best care.
The research done by Dr. Mike Farquhar, who is a consultant in sleep medicine at St. Guys and Saint Thomas's NHS Trust Foundation, shows us why what we can do and why it's important.
We know that it's healthier for us, so it's safer for our patients, and therefore it's better for everybody. And the whole campaign teaches us how to plan your breaks. It teaches us how to work as a team and how to create a take a break culture.
By using the Hulk campaign, we can make sure that none of our staff members become hungry or thirsty, anxious or angry, late or lonely or tired, and we can look at how we plan, prioritise, and pause for our breaks. And if you'd like to download either of these infographics from the vet led website, please do go ahead. In the next section, I'd like to talk to you about checklists for emergency and critical care settings.
Have you ever wondered why it is that sometimes we go into the kitchen and can't remember why we went in there, or why when we have a list in our mind of things we need to get from the local shop, when we go to get back in the car, we realise that actually we've picked up lots of different items to what we wanted and have forgotten key items that we really needed. The simple fact is that as humans we can only hold a certain amount of information on our mental scratch pad at one time. In fact, we can only keep around 7 items on that scratch pad plus or minus 2 on a good or a bad day.
And that's only if you don't get distracted by another task in the meantime. We simply can't be expected to remember everything and therefore when we're in the busy hospital environment to keep our patients safe, we must use checklists. Like many advances in medicine, the safety checklist has its history rooted in the military.
In 1935, the US Army Air Corps started a final set of aircraft evaluations for a contract to supply the US Army with potentially up to 200 long-range bomber aircraft. There were 3 aircraft competing for this large and lucrative contract, one of which was the Boeing Model 299. Legend has it that all the initial evaluations consisting of about 40 hours of flight time had gone in Boeing's favour, and the final flight was a mere formality.
Boone's entry had already earned itself the name the Flying Fortress as it could carry considerably more bombs and fly further and faster than either of the other two entries. Flying the Model 299 that day were two highly experienced army pilots, Boeing's chief test pilot, along with a bow mechanic and a representative of the engine's manufacturer. After takeoff, the Model 299 began to climb, but within a few seconds, the aircraft stalled and fell to the ground, bursting into flames upon impact.
Although all on board escaped or were rescued, both pilots later died of their injuries. Compared to a typical plane at the time, the Model 299 was a complex aircraft with additional controls and instruments that required attention. Finding no evidence of mechanical malfunction, the accident investigation team assigned to the crash concluded that it was caused by pilot error.
Evidently the pilots had made a simple but fatal mistake with one of the new controls, leaving the elevator and rudder controls locked. A newspaper at the time went on to state that the Model 299 was just too much plane for one man to fly. This could have been the end of the story, but for a huge potential advantage, the bomber would give the US Army if it could be flown safely.
So although the main contract was for the Douglas DB-1, a dozen Model 299 planes were purchased for testing purposes. After some deliberation, the solution of the problem was simple, ingenious, but most of all effective. The pilot's checklist.
It turned out that the plane was not too much for one man to fly. But merely too much for one man's memory, and a simple checklist could ensure that none of the crucial steps during the key periods of flight were forgotten. Four checklists were initially developed.
Take off flight before landing and after landing, and all pilots were taught how to use the checklist as part of their normal flight training. The initial 12 Model 299s tested by the army went on to fly almost 2 million miles without serious incident, and the army went on to order over 10,000. The army renamed the aircraft B-17, and it became an icon, a symbol of power for the US Air Force.
The checklist idea was so successful that it enabled aviation and aeronautical engineering to become more and more complex. Checklists were developed for more and more parts of the flight for emergency situations, as well as more routine situations. As an example, checklists were developed for almost every part of the Apollo moon missions, and all our astronauts were trained in how to use them and to write them.
Each of the Apollo 11 astronauts logged over 100 hours of time familiarising themselves and adapting these checklists. In fact, the checklists was so integral to the success of the Apollo moon landings that astronaut Michael Collins coined them the 4th crew member. In 2006, Atul Gundde was approached by the World Health organisation, who had noted a steep increase in the amount of surgery being performed which had affected the quality and the safety of that surgery, and it had now become a big issue.
A team was gathered with the remit of improving safety from within hospitals and reducing harm, and something that was cheap, simple, effective, and transmittable was required. They created the checklist by looking at the key areas where common problems developed. They tested it in 8 hospitals across the world.
4 were in high income countries America, UK, Canada, and New Zealand and 4 in lower or middle income countries such as Manila, Jordan, New Delhi, and Tanzania. And they collected data for 3 months before implementation and for 3 months afterwards. At first, Asel Grande was worried how meagre the intervention was and that they hadn't provided any new equipment, no new staff, and no clinical resources to the hospital.
But what they found was amazing. A 47% reduction in death rates, a 36% reduction in major surgical complications, and in fact, major surgical complications in all eight hospitals fell by 36%. Infection and death rates dropped by 50%, and equally important, the healthcare providers involved began to believe in the power of checklists.
Many had started out suspecting that this was just another bureaucratic distraction from the real business of caring for patients, but 3 months later, 78% of participants said that they'd personally seen the checklist prevent an error in the operating room, with 80% saying it had improved patient care. We know that this research has been echoed within the veterinary profession. Thierman etal in 2021 noted a decrease in anestheia duration from using the checklist, and increased administration of planned preoperative antibiotics before incision, and an increase in completed safety measures.
There was also a decrease of unexpected return to the operating theatre and a decreased odds of perioperative and postoperative surgical complications from 40% to 29%. There was also a reduction in postoperative surgical site infections from 7% to 3%, and the odds of occurrence of more than one complication reduced from 40% after implementation of a surgical safety checklist. Understanding the powerful improvement that safety checklists can offer, we now need to consider how we can implement checklists within the emergency and critical care environment.
And you'll see here an example of an ICU placement checklist, a checklist that's used when placing chest drains, central lines, PI lines, arterial catheters, and O tubes. You'll notice that again it falls into 3 sections prior to sedation, prior to placement, and before anyone leaves. The World Health organisation recommends that a single person should be made responsible for performing the checklist.
In practise, this is often the nurse, although any member of the team may prompt the checklist. The responsible person should feel empowered to ensure that all members of the team listen and participate attentively to the checklist so that communication is effective. Non-urgent disruptions or interruptions should be discouraged, and the person leading the checklist should feel comfortable stopping the flow of the checklist to politely remind all personnel present that their full attention is required.
If there's difficulty confirming a point, for instance, the patient's identity or confirming the owner's consent, the checklist should be halted and only resumed when confirmation is gained. To understand how we can use checklists effectively, we can move through this list of points. We need to make sure the checklist is triggered at the appropriate points.
We need to make sure that the correct and complete team are present throughout. We need to make sure that the checklist is carried out at an appropriate time and that the start and the end of the checklist is verbally declared. As I have already described, the World Health organisation suggests that a single person leads the checklist.
We need to make sure that other duties are paused unless they're critical duties so that everybody remains engaged and involved. And we should only continue the checklist when verbal confirmation of the previous section is given. We want to use a challenge and response style to make sure that it's effectively adopted, and all items need to be consciously checked.
The checklist should be physically referenced throughout and it should be completed in its entirety without interruptions. Care bundles can also be used to huge effect and were part of both the 10,000 Lives campaign and the 5 Million Lives campaign in human healthcare. Care bundles are 3 to 5 evidence-based interventions that are grouped together because they are known that when they are performed together they have a better outcome than performed individually, and they're aimed at increasing patient safety and improving quality of care in a variety of conditions in critical care medicine, these include sepsis, cardiac, and respiratory failure.
Within international healthcare, bundles have also been strongly promoted in critical care. A key example of this is the surviving sepsis campaign. The International collaboration initiative aimed to design and implement a care bundle approach to improve survival from severe sepsis by 25% by the year 2009.
We have also probably heard of ventilator care bundles and central line bundles. Care bundles are known to directly benefit the patient, to result in reduced ICU stays and reduced costs. Non-technical skills have been found to be responsible for causing adverse and unexpected outcomes in veterinary practise.
In this section, we will find out what non-technical skills are needed for safe and effective care and consider what steps we can put in place to reduce the chance of error occurring. Non-technical skills are the cognitive, including situation awareness, task management and decision making, social, including leadership, teamwork and communication, and personal resource skills including stress and fatigue management, that are important for safe and effective task performance. Failures in non-technical skills have contributed to many dramatic accidents in recent history, such as Piper Alpha, an oil platform in the North Sea that suffered a fatal series of explosions in July 1988, the Tenerife air disaster where two planes collided, resulting in over 500 fatalities, the Hillsborough football disaster, wrong site surgeries, and chemotherapy overdoses.
Despite having been studied extensively in other high risk industries such as aviation and healthcare, researchers have only just begun to investigate the non-technical skills important in veterinary practise. We're going to look at 3 of the non-technical skills that are particularly important for working in the critical care environment and What tools associated can help us provide more safe and efficient care. The non-technical skill of situational awareness is known as knowing what is going on around you.
The first level of situational awareness allows us to gather information through our senses, through verbal and nonverbal communication, through watching and listening. We're able to gather information that tells us what's going on in the environment. Level 2 then helps us interpret that information, to understand it and to understand it in relation to the goals and objectives of the procedure or what's going on around us.
The third level of situational awareness, level 3, is the projection of future status or anticipating future states. Level 3 is achieved after perceived information is understood in relation to the goal and objectives, and is the ability to predict what those elements will do in the future. So for instance, the experienced nurse might be able to anticipate the surgeon's next move and be prepared with the instrumentation that they need.
A loss of situational awareness can result in serious compromise to patient safety if it's not recognised by either individuals or the clinical team, and therefore it's important that we understand what the red flags are that we might pick up if somebody is losing situational awareness and perhaps becoming task fixated. So one of the red flags would be fixation on a single task to the exclusion of all else. Failure to adhere to accepted practise or not responding to warning signs.
We also know that a failure to communicate effectively can indicate a lack of situational awareness or confusion or uncertainty that cannot be resolved can also lead us to understand this. Unresolved discrepancy between two sources of information or leading questions can create concern that situation awareness may not be present. And displacement activities.
May also alert us. It's important to recognise that when somebody has lost situational awareness, the observer may simply feel that something doesn't feel right, and we must always attend to that feeling and do our best to understand it and take the necessary action to make it right. If you're concerned that somebody has lost situational awareness, we can use appropriate or graded assertiveness to help us rectify this.
Appropriate or graded assertiveness is a technique used in the health industry to improve communication when challenging unsafe practise is a process of structured thinking, communicating, advocating, and direct in care during stressful or crisis situations. Graded assertiveness refers to the gradual increase in confidence when challenging unsafe practise, and this process is described by four-tiered framework with the acronym PACE. Probe alert challenge emergency, which includes scripture sentences to respond to concerns or red flags and refers back to the objective findings and observations about the patient rather than direct criticisms of the actions of other health care professionals.
If we wanted to use appropriate assertiveness in practise, we could use the pace acronym. We would start by probing, raising concern, or gaining attention using an open question. Perhaps, are you aware that your oxygen saturation is quite low?
Then if we didn't feel like the situation had been rectified, we could move to alert. We would use the person's name, Bob. Are you aware that your oxygen saturation is now 80%?
Then we would move to challenge. We would repeat the person's name and concern with urgency, challenge the current actions with suggestion, suggested solutions. Bob, are you aware that your, your oxygenation is now 80%?
We need to intubate the patient and provide IPPV. If this still does not rectify the situation, we may have to move to emergency. At this point we need to be prepared to physically intervene and take over.
We know that another simple, yet highly effective strategy for helping people increase patient safety is the theatre cap challenge. It was found that the single most important thing to improve non-technical skills in the operating throughout room is to know the first name of the people on your team. Knowing and recognising team members by name is associated with increased trust, work engagement and clinical improvement, and studies have shown that knowing the names of other people on your team greatly improves prevention of adverse outcomes.
The theatre cap challenge led to an increased propensity to speak up from 45 to 85%. When we know each other's first names, it's easier to break task fixation, easier to regain situational awareness, and that's because of the phenomenon called the cocktail party effect. You know yourself, if you're at a party and you hear somebody talking about you, your ears will prick up.
You want to know what they're saying, and this is the same in emergency situations. If you're trying to break task fixation, if you're trying to bring somebody back to you or gain their attention. Using their first names is incredibly powerful.
And it can obviously be the the the difference between a patient receiving the care they need and not. Therefore, it's so important that we have our names easily and readable and displayed upon our uniforms somewhere. We've already established that communication is absolutely fundamental to the safety of our patients, but it's important that we recognise all the tools that are available for us to use.
We've talked about checklists and we've talked about pre-briefings. We can add handover tools and care bundles and many other tools to improve our communication. And to improve our care in the ultra dynamic environment.
We need to make sure that we understand that written communication is the least rich way of transferring information and the most rich way of transferring information occurs during face to face communication. We also need to understand that words form only 7% of how our message is interpreted with a large amount of the understanding from a conversation coming from nonverbal communication and the tonality of our speech. So we need to make sure that we're aware of all of the tools we can use to ensure that communication is as successful as it can be within our environments.
And we need to accept that good communication with not only the team but also with the patient's owners is essential to reduce complications. We need to remember that we can only keep a limited amount of information on our mental scratch pad and therefore we may need to use written communication. In addition to verbal communication to make sure that our patients' carers and owners understand what care they need to undertake at home.
As I've already mentioned, the communication structures that we use in veterinary practise include patient safety briefings, which we've already covered, handovers which will go on to cover, closed loop communication, feedback and debriefing, and emergency communication like the PACE acronym we've already mentioned. Handovers can be hugely informative when we're managing patient safety and patient care, and SAS situation, background assessment and request. The formula for that was first developed by the military specifically for nuclear submarines to use in situations which were stressful or time pressured.
It was then used in the aviation industry, which adopted a similar model before it was put to use in healthcare. SBA is not only recommended for the use of verbal communication but also for written communications and entries into clinical notes. A request to provide an SBA update or handover ensures that the correct information is delivered in a concise, precise, and timely manner.
Within human healthcare, the SBA became the ISA because it was identified that we needed to not identify the person speaking and their role and their responsibility, but also the identity of the patient, and that was fundamental to the rest of the handover. So we use handovers to transmit the information that cannot be gathered just from reading the clinical notes or the kennel charts. So we need it to be concise.
We need to consider what the person needs to hear to enable them to paint a mental picture. We need to make sure it's consistent. We need to make it easy for the people delivering it, so we want to reduce anxiety and increase mental capacity by using an acronym that everybody can easily remember.
We need to make sure that it's relevant. The information we're transmitting is relevant and it's like I said, it's not just freely available within the clinical notes. We want to make sure that we're inclusive during the process and we ask questions and encourage closed loop communication.
And we want to make sure that we break it down into standardised chunks because we know that our brains work much more effectively and learn and engage more easily with information when it's in chunks and when it's standardised regardless of how you choose to standardise it to your particular practise, using that standardised version in that structure is really, really important. So key thoughts, avoid repeating facts and numbers, which we've already got recorded, we don't need to do that and make sure we invite questions at the end of each patient handover, so each is bar. So the ISA starts with the identity of the patient.
We want to identify ourselves, our position, our location, and who we're talking to. And then we want to identify the patient, their name and a brief information about their age, their sex and location, the signal of that patient. Then we go on to stating the situation, the reason that you're calling, if it's on the telephone or the reason for the handover.
At this point we need to mention if it's urgent, we need to tell them why it's urgent. Then we go into the background, tell the story, update them to the current problem again, make sure that you're giving them the relevant history, but without all the information that the clinical notes would given them, just what you really need to know from this particular patient at this moment. So we want to talk about a relevant examination, any test results that we've had back, what their management is and previously what's gone on for the patient.
Then we move on to assessment, what you think is going on now and then request. So we'd like to state the request, whether that's that they take this patient as a handover to their care after perhaps a surgery and this might be an exchange between an anaesthesia nurse and a ward nurse or people in those roles. And Then invite questions thereafter.
Closed loop communication is a communication model which originated in the military. It is based on verbal feedback to ensure proper team understanding of a meaningful message. Closed loop communication is a three-step process where firstly the transmitter communicates a message to the intended receiver utilising their name when possible.
For instance, in the emergency care setting, this might be asking for a resuscitation drug. So it might be that the transmitter communicates the message to me to say, Helen, please can you get 0.2 mLs of adrenaline.
The receiver then accepts a message with acknowledgement of receipt via verbal confirmation seeking clarified clarification if required. So in response to that initial request, I would then reflect the information back saying, was that 0.2 mLs of adrenaline you requested.
And they would confirm that the message has been received and correctly interpreted, therefore closing the loop. Research from veterinary and human healthcare shows us that teamwork influences errors, and it's one of the key competencies required for successful delivery of skills. We know that researchers at Google found that how teams work together had a greater impact on performance than individual capacity and identified 5 key ingredients required to create a high performing team.
Those ingredients are psychological safety, the ability for team members to feel able to speak up without fear of retribution, punishment, or embarrassment. Dependability, structure and clarity of knowing what your roles and responsibilities are, meaning and purpose, and making a difference. Within the veterinary industry we're very, very lucky that me and purpose and making a difference come in spades.
We have oodles of that. It's really important that we understand. How we work with teams and what we can do to increase that that element of our working.
In the final section of this webinar, I want to want to spend a moment talking about how we can go home happy, how we can ensure that every member of our team goes home feeling OK, and how we can learn through talking. Everybody knows the spine chilling, nauseating feeling when you realise you've made a mistake, irrespective of your professional experience. The slow motion moment where the clippers roll off the table and smash onto the floor because you were rushing and didn't put them back properly, or the terrible realisation that you've miscalculated the sedation you drew up and have just overdosed your patient.
Head in your hands, you count the cost. Panic rising, knowing that you need to talk to someone, fess up and put it right, whilst drowning in a fear that you will be in big trouble, struck off, fired, or financially liable. A just culture considers wider systemic issues when things go wrong, encouraging staff to be able to freely admit inadvertent error without fear of punishment so that incidents can be investigated and the cause understood to guarantee safety can be improved.
It's the midpoint between a blame culture and a no blame culture. Just culture balances learning with accountability. A blame culture is in some ways a natural human reaction to an adverse event.
We seek to find who caused the error and punish them so that the problem doesn't occur again. A no blame culture suggests that anything goes. We know that some situations are not acceptable and we need to draw a line in the sand.
A just culture seeks to move away from asking who caused the problem and asks why and what happened. Ensuring that a just culture is employed in practise means that if the clipper smashed, the patient receives a loader dose, or despite your best efforts, the worst thing you can imagine happens. You know that you can share the experience in a non-judgmental and supportive environment.
Without the fear of recrimination. And you'll have the support of the team to work together to make suggestions for improvement. If you find yourself with a few moments after this webinar, I encourage you to Google a restorative just culture at Mersey Care by Sydney Decker.
It's a short film explaining how they implemented restorative just culture in an NHS hospital. To improve the ability of staff members to perform and to reduce the the knock-on effects of incidents affecting individuals. Within a just culture, within a restorative just culture, we look to ask who was hurt, what do they need, and whose obligation is it to meet that need, rather than apportioning any blame or criticism.
As part of a just culture, it's really important that every member of the team feels safe to speak up, that feels psychologically safe, to raise their thoughts, their ideas, their concerns in an environment where they won't be made to feel silly or that they're wrong and they won't be criticised or blamed. We know that it's hugely helpful to be able to talk about adverse events. We can prevent others making the same error again and therefore we can improve patient care.
By discussing what went wrong and what went right in the case with compassionate colleagues in a safe space, we can shed some of the upsetting feelings we encounter. We know that using an easy debrief structure like the stop 5 is hugely helpful. It enables us to pause for just 5 minutes to summarise the case, look at the things that went well, what the opportunities are to improve, and it points to the actions and responsibilities.
But before any of these things are undertaken, we can check in with others to check that everybody's OK. So we can debrief as a team to learn from experiences because these experiences might play on our mind, especially the mistakes you think you might have made. And at the end of the day, the shift, the procedure, debriefing as a team and sharing thoughts to enable learning and maintaining mental well-being is so, so important.
Using a critical instant reporting system, whether it's something like that safe or an in-house tool, is so important too. It helps us understand why it makes mistakes happen. It helps us develop solutions.
It helps us comply with practises and schemes, and it helps us support second victims. When we know better, we can do better. And if we collect instances where things haven't gone where as if we've expected, then we can begin to see trends and really sit and think about how we can put solutions in place to stop these mistakes happening time and time again.
When I visit practises, sometimes the mention of mortality and morbidity meetings can make people feel uneasy. And so for that reason, I tend to reframe them now as learning discussions. Learning discussions provide an open, non-judgmental, confidential, and collaborative setting for the review of adverse events through identification and presentation of a case where an adverse event has occurred.
Multidisciplinary reflective discussion, analysis, and identification of contributory factors provide a powerful tool to educate staff and improve patient safety and care. If you currently don't use learning discussions or M&Ms in your practise, you could always start with something that went really well. And I would always encourage practises to look for excellence and practise a reflection on those cases too.
Getting together to discuss what went well and how we can learn from it and repeat that more often is just as important as analysing things that didn't go well. We also have to consider that it doesn't always have to be a patient at the centre of an M&M or a learning discussion. When we've had interactions with clients that perhaps have gone extremely well or have been extremely difficult, it can help to use a learning discussion in that situation for all areas of the practise to support everybody at every level from reception or the client facing team right through to ward assistants.
And beyond. It's important that we all learn from instances that happen. And we understand that these things do happen and by learning and sharing these thoughts and scenarios, we can become better and stronger at our jobs.
As I've already mentioned, it's vital that we learn from excellence as well as error. If we consider the distribution of error across a bell-shaped curve, then actually the proportion of times that things go incredibly well is very similar to the proportion of times where things don't go as we expected or things go wrong. We need to look at both ends of the curve, the spectrum, to understand how we can make things go right more times.
As humans were biassed to look for the negative and learn from the negative. But by learning from the positive and being grateful and practising gratitude and acknowledging people for the fantastic work and contributions that they give. We can ensure that our teams go home happy.
I really hope you've enjoyed this webinar and have taken home a few tips and tools that you can use to improve patient safety in the ultra adaptive veterinary emergency care setting. We've looked at how to start a good day. We've looked at huddles, briefings, and how to plan and prioritise and pause for our breaks using the halt.
Campaign We learned a little bit about checklists, how they originated in the military, were distilled through human healthcare, and now how we could employ them within the emergency care setting. And we've considered the non-technical skills, situational awareness, and how we can use the theatre cap challenge and the PACE acronym to help us overcome situational awareness deficits and task fixation. We've looked at the importance of communication and the importance of teamwork.
And we've also understood the importance of improving patient safety through learning through talking, through the importance of reporting errors so that they can be collected into themes and so that we can address them in that respect. How we can debrief for 5 minutes after a difficult day or when things go really well to make sure that we all go home feeling happy and how we can use learning discussions to discover what went well and what we would do differently next time. Thank you so much for your time.
Please do reach out if you have any further questions.