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Clinical Audit and Black Box Thinking – is this for me?

Recently there has been a lot of interest in the general and veterinary press about checklists and clinical audits, suggesting that with checklists and clinical auditing everything will turn out perfectly forever after.

However, checklists do not eliminate errors. There are, apparently, checklists for baggage handlers, but in my personal experience, that does not appear to prevent my bags from turning up in a different country to me. Happily, for those of us who take airplanes occasionally, checklists that the pilot uses up in the cockpit appear to virtually eliminate errors. So, we need to ‘buy in’ to checklists – we need to believe in them and see the results. We need to record the errors and applaud when our initiative (the newly introduced checklist) achieves a decrease in those errors. This essentially means that nurses, vets, receptionists and assistants must all believe that they work.

Recently, at the end of a long procedure, my theatre nurse ran through the checklist while I was preparing to close a large celiotomy incision. Just at the point when we would rather be talking about plans for the weekend and aren’t we pleased with ourselves for successfully carrying out the procedure, she insisted on going through the checklist and stopped our chatter: “Procedure logged? Samples collected? Sharps off the trolley? Swab count?” Swab count (which I had already done once, but did again under her pressure) persistently threw up one swab short. 10 minutes later it was found nestled in the omentum. Definitely worth every second of the time it takes to do the checklist and very sobering.

This brings up a different question. How do we know if the check list is making any difference?

We like to hear that hospitals treating humans carry out audits to look at the outcomes of their surgeries and how often treatment is successful. However, in the veterinary profession we are very bad at this introspection and self analysis. In general practice, there are many repeatable procedures that could be audited. Neutering, prophylactic dental work or simple lump removal with primary closure. These are all comparable procedures with measurable outcomes. It may be time consuming, but with the right protocols, you should be able to work out a way to do it that is part of your routine. Reporting morbidity and mortality is a good way to start and helps to encourage the team to look at outcomes and think about them. Questions you might like to ask your team include ‘how many patients die unexpectedly in the hospital, vs those that are put to sleep?’ Do you know how many of your patients are put to sleep for financial reasons and how many are put to sleep for clinical reasons? When you look at morbidity, do you know how many of your patients lick or chew their surgical wounds? Can you reduce this number in any way by improving analgesia or owner instructions? If you know what your starting figures are you can see if your checklists improve these figures.

The next question is what do we expect to be normal?

Owners sometimes tell us that they were told it is ‘normal’ for a dog to take 2-3 days to recover from an anaesthetic. They are therefore surprised when they pick their dog up from us and find them bouncing off the walls. There is a difference in expectation of a ‘normal’ outcome here that cannot easily be resolved by checklists or auditing. Is it ‘normal’ for a bitch spey to take days to recover from her surgery? Probably not – perhaps we should raise our expectations for recovery as well? A surgical wound should look dry and healthy 2-3 days post op with no inflammation; if it is not, then we should consider that as abnormal and wonder why it was so for that case.

Clinical auditing requires a certain level of curiosity and challenging preconceptions which is sometimes uncomfortable, but ultimately rewarding. However, it also requires all staff to be encouraged to report complications, or near misses with complete impunity, and more importantly, it requires clinicians to critically evaluate events without using euphemisms or excuses.

‘Black box thinking’

This thought brings me on to the current trend, ‘Black box thinking’. It refers to the fact that the aviation industry has the highest safety record across all industries worldwide. This is largely attributed to the fact that all errors are recorded, analysed and made available worldwide with a no-blame culture. Thus, the aviation industry can respond to technical, psychologic and physical errors. In the medical and veterinary professions our language is a profusion of euphemisms. We refer to an ‘unexpected complication’, ‘unanticipated finding’, ‘unexpectedly rapid progression’. We do not openly accept and respond to the challenge of a bad outcome that might have been avoidable. If we did, the dialogue over an incident would be open and constructive and our safety record would improve. We would understand where errors come from (stress, failure to listen to junior colleagues who are more objective as they are observers, lack of facilities, failure to organise stock to be easily available in emergencies, failure to record and use check lists etc etc) and we would be able to address them and resolve issues in advance of the next event.

Clinical auditing combined with black box thinking could (and should) completely change the way we work in the clinic, opening our eyes to new ideas and better ways of working. Responding to errors is the most effective way to improve the way we do things whether it is clinical outcomes, owner satisfaction and retention, or financial returns.

Ref: Black Box Thinking. The Surprising Truth about where Success comes from. Matthew Syed 2016

Published: 13-02-2017

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