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errors occur because medical team members are human. Care providers know what to do and how to do it; however, do they always intervene appropriately, every time, in the same manner? Despite our best efforts, patients can receive incomplete or inadequate care. Our knowledge has burdened us: the breadth and depth of what we know have exceeded our capability to deliver upon it reliably. We can overcome our shortcomings by implementing a strategy that reminds us what to do, in the proper order. Veterinary medical checklists are an effective strategy to reduce avoidable errors. Although checklists can be applied to any facet of veterinary practice, anesthesia and surgery are practical starting points for initiating change.
2.4.2 Terms Defined
Checklist: A tool that is intended to reduce human failure by drawing the user's attention to key tasks that must be performed in a particular order and allowing the user to mark off each task as it is performed to prevent missed steps.
Medical Error: An adverse effect of patient care that may or may not be harmful to the patient but could have been prevented.
2.4.3 The Need
Failures occur in every industry, including veterinary medicine. However, few industries have been able to reduce human‐based error to the degree that the aviation industry has reported. Between 1993 and 2013, the number of worldwide flight hours doubled from 25 to 54 million, yet fatalities decreased from 450 to 250 per year [1]. By comparison, 200,000 people in the United States alone are estimated to die preventable deaths annually at the hands of human healthcare [2]. This rate of deaths equates to three fatal airplane crashes per day and would be considered unacceptable to the aviation industry: “Airlines would stop flying, airports would close … [and] no one would be allowed to fly until the problem had been solved” [3].
Comparisons are more difficult to make between veterinary medicine and the aviation industry due to the paucity of studies in the veterinary literature [4, 5]. Most veterinary publications examine anesthetic or surgical complications, not all of which stem from human error. In companion animal medicine, these include hypotension [8–8], dysphoria [9–11], cardiac arrhythmias [8], aspiration pneumonia [12], cerebellar dysfunction [13], blindness or deafness in cats [14–16], and death [17].
A retrospective study examined medical records from 98,036 dogs and 79,178 cats that underwent anesthetic procedures between June 2002 and 2004 in the United Kingdom. Brodbelt et al. determined the overall risk of anesthetic death to be 0.17% and 0.24% in dogs and cats respectively [18]. When categorized by health status, healthy dogs and cats experienced anesthetic death at the diminished rate of 0.05% and 0.11% compared to 1.33% and 1.40% in ill dogs and cats [18]. These percentages are much higher than 0.02–0.05%, which is the range reported for anesthetized people [19–21]. However, how much death is the result of medical error is unknown. Most of what is known is largely anecdotal, which begs the questions “How much error occurs that we don't know about and what can we do to prevent it?”
2.4.4 The Tool
How might healthcare professionals learn from aviators to reduce preventable error, thereby improving safety? There is one tool in particular that the aviation industry has relied upon that has gradually trickled into various facets of human healthcare: the checklist. Checklists may seem too simplistic an approach for the complexities of medical cases but by guarding against two common pitfalls in healthcare, distractions and human fatigue, they are perhaps more important than ever for safeguarding those for whom caregivers are responsible. Checklists are tangible reminders of steps that we may have forgotten to take; steps that we may remember, but fail to carry out to completion; and steps that we may take but execute improperly [2].
In aviation, checklists may be used for ordinary procedures, such as take‐offs and landings, as well as for malfunctions and emergencies. Healthcare as a whole has been slow to adopt this tool; however, human medical providers have gradually piloted, tested, and refined checklists in the following arenas [2, 22–33]:
anesthetic equipment prechecks
communication between team members
emergency codes
infection control
medication dosing
patient diagnosis
patient identification
patient tracking, from admission to discharge
patient transfer from the operating room to the intensive care unit
shift changes and communication between outgoing and incoming nursing staff
surgical planning
surgical procedures.
The World Health Organization (WHO) Surgical Safety Checklist was published in 2008 and remains one of the most widely used checklists in human healthcare today [2, 34].
The adoption of checklists and their success inherently depend upon staff training and resource management; that is, how team members interact with and influence one another [2]. Effective communication with opportunities for debriefing fosters teamwork and the opportunity to learn from mistakes, rather than hide from them [35, 36].
2.4.5 Checklists in Veterinary Medicine
Much of what we know about human‐based errors in veterinary medicine stems from an analysis of liability insurance claims. Surgical errors are overrepresented, including retained surgical tools [5, 37–45]. Because these errors have the potential to increase morbidity and mortality among patients, particularly when their diagnosis is delayed, measures ought to be taken to reduce the incidence.
Checklists in veterinary surgery are an appropriate tool to address surgical instrument retention, among other surgical errors. For instance, a surgical checklist should require a pre‐ and postoperative count of gauze squares, swabs, and sponges [37]. If these numbers are incongruent, then the surgery cannot be completed until all missing items are accounted for. Counting swabs and gauze squares is not immune from human error but it is an appropriate starting point prior to body cavity closure; in human healthcare, the sensitivity is 77% and specificity is 99% [46]. An additional safety measure would be the use of radiopaque swabs [47]. In the event that a discrepancy persists, radiographing the area of the body that was operated on should confirm accidental retention of the missing item within a body cavity.
In addition to surgical errors, medical errors may occur in veterinary practice (see 8.14 Appropriate Handling of Medical Errors). Among these, overdoses of medication and the administration of the wrong medication appear to be most common [5]. Checklists are also important aspects of convergence schedules, to ensure that client communication is managed appropriately (see 9.7 Continuum of Care and Convergence Schedules) and as preanesthetic safeguards (see 9.13 Preanesthetic Considerations).
Checklists are therefore advisable in veterinary healthcare for many reasons, all of which promote patient safety. There is currently no standard checklist to which all veterinary practices subscribe; however, a variety of formats are available in the popular press and can be custom‐fit to suit an individual practice's needs (see Table 2.4.1).
Table 2.4.1 Sample surgical safety checklist for use by veterinary practices as a tool to guard against human error. This checklist can be modified for completeness