Finding the Black Box: Learning from Medical Errors

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

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