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Categorising reported errors and incidents from morbidity and mortality meetings (M&Ms) in a small animal
G Giles1, L A Boland1, N Kirkwood1
1Sydney School of Veterinary Science, University of Sydney, Camperdown, Australia.
Background:
Errors in veterinary clinical settings can lead to patient harm. Morbidity and mortality meetings (M&Ms) are forums to discuss errors and incidents that can lead or have led to adverse outcomes, potential harm or unsafe conditions, with the purpose of improving patient safety in future. Despite growing implementation of M&Ms in veterinary medicine, their effectiveness in improving future patient safety may be constrained by the need for absolute confidentiality during meetings.
Objective:
To pilot the use of a simple framework to categorise errors and incidents triggering M&Ms in a multi-specialty Australian veterinary teaching hospital.
Methodology:
A retrospective analysis of deidentified M&M summaries over 5 years (2018-2023) from a small animal multi-specialty veterinary teaching hospital. Animal demographic and incident information were extracted, classified by incident type and severity of harm adapted from Wallis and colleagues (2019). Descriptive statistics were produced for error category, severity, incident type and quarter of the year they occurred in. Recommendations were analysed using codebook thematic analysis.
Results:
There were 68 cases in total. The most common overall errors were oversight (n = 26/25.0%), drug (n = 20/19.2%), iatrogenic (n = 17, 16.3%) and staff (n = 17, 16.3%). Most cases resulted in temporary harm (n = 36, 52.9%), though 20.6% (n = 14) resulted in death, euthanasia or permanent harm. The most frequent recommendations were 'improving communications and record keeping', improving staff training' and 'ensuring appropriate equipment is available'.
Conclusion:
Categorisation of errors using this simple framework can facilitate sharing of information which can be used to refine practices and improve animal safety, without compromising confidentiality of M&M meetings.
Insights
A simple framework for categorizing veterinary errors in morbidity and mortality (M&M) meetings was piloted. This approach aids in refining practices and enhancing animal patient safety without compromising meeting confidentiality.
Area of Science:
- Veterinary Medicine
- Patient Safety
- Clinical Quality Improvement
Background:
- Veterinary clinical errors can cause patient harm, necessitating systems for review.
- Morbidity and mortality (M&M) meetings discuss adverse events to improve patient safety.
- Confidentiality concerns may limit the effectiveness of current M&M practices in veterinary medicine.
Purpose of the Study:
- To pilot a straightforward framework for categorizing errors and incidents within M&M meetings.
- To assess the utility of a new categorization system in a multi-specialty veterinary teaching hospital.
Main Methods:
- Retrospective analysis of deidentified M&M summaries from 2018-2023.
- Classification of incidents by type and severity of harm using an adapted framework.
- Descriptive statistics and thematic analysis of recommendations.
Main Results:
- 68 cases were analyzed, with oversight, drug, iatrogenic, and staff errors being most common.
- Over half of cases resulted in temporary harm, but 20.6% led to death, euthanasia, or permanent harm.
- Key recommendations focused on improving communication, record-keeping, staff training, and equipment availability.
Conclusions:
- A simple error categorization framework can enhance information sharing for practice refinement.
- This approach supports improvements in animal patient safety.
- The framework maintains the confidentiality of M&M meetings.
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