Coping with Mistakes in Veterinary Medicine | Episode 46 | Reviving Vet Med

Mistakes are an inevitable part of veterinary practice, and if you’ve been in the field for any length of time, chances are you’ve made one. In this episode, we delve into the various types of mistakes that can occur, from minor errors like miscalculating a drug dose to more serious ones that may have significant consequences. Drawing from personal experiences and professional insights, we explore the emotional toll mistakes can take and share strategies for coping and thriving in their aftermath.

We discuss the importance of technical learning, full disclosure, expanding perspectives, and finding support among colleagues. Additionally, we emphasize the power of self-compassion in silencing the inner critic that often emerges after a mistake. Whether you’ve just made a mistake or are supporting someone who has, this episode offers valuable tools to help navigate the challenging yet common experiences that all veterinary professionals face.

Resources

Article: Medical errors cause harm in veterinary hospitals (Frontiers in Vet Sci 2019): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6370638/ 

Article: Veterinarians' experiences with near misses and adverse events (J Am Vet Med Assoc 2018): https://avmajournals.avma.org/view/journals/javma/252/5/javma.252.5.586.xml 

Article: Veterinarians’ emotional reactions and coping strategies for adverse events in spay-neuter surgical practice (Anthrozoos 2018): https://www.tandfonline.com/doi/abs/10.1080/08927936.2018.1406205  

Download: Self-Compassion Exercises After Making a Mistake: https://revivingvetmed.kartra.com/page/selfcompassion 

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Transcript

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You can also book a demo call with no obligation to sign up. Discover how Scribe Note can help streamline your workflow and ease your day. Hi everyone. Welcome to another episode of Reviving Vet Med. In this episode, we will be discussing the unfortunate but very common occurrence of mistakes in veterinary practice. If you've been in veterinary medicine for any length of time, then chances are you have made a mistake. I know I have. From as minor as miscalculating a drug dose or misreading a lab result to as major as misinterpreting a radiograph and causing a patient's death. Topics we'll be talking about today include the different mistakes that can happen in veterinary practice and, most importantly, how to cope when they do. I'm very excited to be back recording twice-monthly podcast episodes, and this one is an important one. 

So, so let's go ahead and get into the episode. This is the Reviving Vet Med podcast, and I'm your host, Doctor Marie Holowaychuk. My mission is to improve the mental health and well-being of veterinary professionals around the world. So, if there's one piece of advice that I wish that I had been given earlier on in my career, it is definitely the fact that we are all going to make mistakes at some point, and probably more than once. And this is definitely something that wasn't talked about a lot when I was in veterinary school a couple of decades ago, and thankfully is something that we're talking more about today and doing more research on to better understand. And yet still, there's a lot of information lacking that is circulating to help support people in recovering in the aftermath of a medical mistake. 

And so I want everyone to know who's listening that if you have made a mistake, first of all, you are not alone, and there is a way through this, and that's what the focus of today's episode is going to be. Now, I can remember the very first mistake that I made, at least the very first one that I know that I made. I'm sure that there was others before that, and it was during my residency. I think I was in my first year of my residency, and it was a minor error. It was an overdose in buprenorphine that I drew up for a cat. 

It was a pretty large cat, and I didn't think much of it, but I had miscalculated the dose as a 0.1 mg per kg dose instead of a 0.01 mg per kg dose, and the cat was extraordinarily sedated, and thankfully, there was no consequences from that. And the cat was able to just kind of sleep it off and work its way through. In fact, I didn't even realize it until I went to give the cat the next dose of buprenorphine, during which I recognized, oh, okay, this is a much smaller volume than what I gave previously. And in hindsight, you know, recalling the nurses' concerns that the cat was looking much more sedate. So that was the first one that I can remember. 

I think the biggest mistake that I can think of in my career, and the worst mistake certainly, that I've made to date, involved a patient by the name of Lacy, who also incidentally, was treated during my residency program. And Lacy was an older terrier mix that had a plethora of different problems. She was under the care of the internal medicine service for things ranging from Cushing's disease to liver insufficiency to, I think she had been diagnosed with a small brain tumor at one point and various other concerns. And for this hospitalization, she was in the ICU being managed for an acute episode of pancreatitis, and she had been in our step-down ward, actually, for a number of days. We were really overstretched in ICU. 

There weren't a lot of cages available, and I had been walking past her cage for a couple of days in the intermediate care. This was when I was a resident intensive care and emergency at NC State University, and one of the nurses had actually brought to my attention, you know, "Lacy's been here for a few days. We're not really sure what's happening with her, and she hasn't been eating, and it's been three days now since she was admitted." And long story short, I recommended to the medicine team that we place a feeding tube for Lacy and move her into the ICU and give her some more intensive care. And so the medicine team agreed to this, and we coordinated between our two services that we would get the tube placed and we would get the feeding started. 

And so, because I had so many patients in the ICU, including a ventilator case and some other things going on, I asked one of my nurses to place the feeding tube. And so my nurse went ahead and placed the feeding tube with the assistance of a couple of students that were in the ICU helping. And the tube was placed, and I looked at the x-ray, and the tube had flipped back on itself within the esophagus so that it was in the esophagus. And I could confirm that. But instead of going down to the distal portion of the esophagus and into the stomach, it had flipped back on itself. 

So I asked my nurse to just, you know, pull the tube back out a little bit, and that should straighten out the kink, and then, you know, push it back in, and we should be all good. And so the nurse let me know that she had done that. And I quickly just took a peek at the next radiograph that was taken and saw that the tube was facing forward towards the diaphragm, not in the stomach, but towards the end of the diaphragm, past the heart. And I thought, okay, the tube's in place, and let's go ahead and feed now. What I didn't know, because of a lack of communication and because I did not fully evaluate the x-ray, is that my nurse had actually removed the tube entirely and replaced it from scratch. 

So she had not just backed it out and replaced it, she had taken it all the way out and fully replaced it. And unfortunately, in doing so, the tube was misplaced in the trachea and had moved into one of the distal bronchi, and I did not recognize this in my re-evaluation of the x-ray and Lacy was fed into her lungs. So suffice it to say, there were complications from this happening, and I was not involved with the remainder of Lacy's case. The intern that was on overnight contacted the medicine doctor when Lacy started having some signs of respiratory distress and coughing. And sadly, Lacy passed away shortly thereafter when she experienced cardiopulmonary arrest. So this is the case. Even talking about it now, I get emotional. I will never forget this situation and the mistake that I made. 

And this is an example of one of the dire consequences that can happen when we do make mistakes. And I think it's important to recognize that there are many different types of mistakes that we can make. We can certainly make mistakes with drugs, like I had mentioned before in my buprenorphine example. So, you can draw up the wrong drug, you can calculate the wrong dose, you can give the dose to the wrong patient. Lots of different situations there. You can also make mistakes with procedures other than medications. So, you can be doing procedures like surgeries or other procedures and make mistakes that way. There can be mistakes with systems in terms of missing treatments or having problems with protocols. There can be mistakes in communication, where there's confusion over the orders. Of course, that happened in the situation with Lacy. 

There can be mistakes with lab specimens. We can lose specimens or mislabel samples and end up having mistakes that way. And then, of course, there can be oversight mistakes where we simply make a mistake because we miss a diagnosis or we misread an x-ray, as in my example. And in most of those cases, or many of those cases, there's a deviation from the standard of care. So, in Lacy's situation, of course, we did follow the standard of care in taking an x-ray after her tube was placed, but the mistake was made in missing the diagnosis of the tube positioning in the respiratory tract. So I mentioned this at the beginning, but I want to restate it here now. And that is the fact that everybody makes mistakes. If you haven't already, I promise you will. 

Not because I want you to, but because we're human and we are all going to make mistakes. And another thing to keep in mind is that despite the fact that we all make mistakes, not all mistakes cause harm. So, when we think of mistakes that can happen, we generally think of three different consequences. So, we can have a near miss where we make a mistake, but the mistake does not reach the patient. If it had reached the patient, it could have caused harm, but it didn't. So, an example of a near miss would be drawing up an exponential dose of insulin, for example. And then you recognize, "Gosh, why am I using such a big syringe to draw up this insulin?" And then realizing, okay, this is not the correct dose that I've calculated. 

Another type of consequence from a mistake is a harmless hit. So, this would be the example of the cat with the buprenorphine, where the error reached the patient, but the patient was not harmed. So, yes, the cat was sedated, but thankfully, there were no other consequences, so that would be considered a harmless hit. The third consequence of mistakes that can happen is that it actually creates an adverse event where the mistake reaches the patient and causes harm. So, the example, of course, would be Lacy and her misplaced feeding tube. So, I mentioned previously that we do have a lot more information on mistakes, specifically in veterinary hospitals. There was some really great research that I'll link to in the show notes that was done at Cornell University a few years ago, looking at the rate of medical errors that happen. 

And what they found is that there were 560 medical error events reported, which equated to five mistakes per thousand patient visits. So, to put that in perspective, in human primary care, on average, there is one mistake per thousand patient visits. Now, the Cornell hospitals that were included, of course, were the large and small specialty hospitals, and then a referral specialty hospital that is affiliated with Cornell. And so it's important to note that in emergency settings and in specialty settings, we do see a higher rate of mistakes compared to general practice. But hopefully, that just puts it a little bit into perspective. Now, what they also found in their research was that 15% of mistakes resulted in harm and 8% of mistakes resulted in permanent disease or death. 

So, there could be some pretty big consequences that happened as a result of the mistakes that were made. Now, another important research study that I want to draw your attention to comes from an article published by Doctor Kogan et al. in the Journal of the American Veterinary Medical Association back in 2018. And I'll link to that as well in the show notes. And this was a survey study wanting to look at medical errors and their personal and professional impact on veterinarians. This was actually a survey that went out to members of the Veterinary Information Network, or VIN, and the study was conducted in the fall of 2015. 

Now, again, this puts it in perspective just how common medical mistakes are, because 74% of people who responded, those veterinarians who responded, were involved in at least one medical mistake, 64% of those were a near miss, and 30% of those were an adverse event. So, again, a vast majority not impacting the patients, but about a third of them negatively impacting patients. Now, it makes sense. I mean, if you think about it, if you make a mistake and it doesn't harm the patient, you think, "Oh, phew, you know, thank goodness we've missed hurting someone. I feel bad about that." And versus, if you do cause harm, then that's more likely to impact you psychologically. And that was what they found. 

When they looked at the results of this survey, what they found is that adverse events or mistakes that led to adverse events were more likely to have a longer-term negative impact on veterinarians' professional and personal lives compared to near misses. So, they tended to last more than a week compared to those near misses, where it was generally a few days, and the veterinarian felt like they were getting over it. So, again, I think this is an important thing to keep in mind, that you still likely are going to be impacted when you do participate in a near miss or a harmless hit mistake. But if you are to experience an adverse event and it was caused by a mistake, then chances are you're going to have a much more long-lasting impact. 

So, what kind of an impact can we see amongst veterinarians and other team members who experience mistakes? Well, there was a research study that was published in 2018 that specifically surveyed veterinarians in high-quality, high-volume spay-neuter clinics or shelters. And obviously, if you're working high volume spay-neuter, you are going to have lots of opportunities for mistakes. Right? Anytime we're doing surgery, anytime we're doing anesthesia, especially at high volume, that is going to put us at risk for mistakes. And so they were able to get the responses from more than 30 veterinarians who were quite experienced. They'd been working for a median of 17 years and a median of eight years in a high-quality spay-neuter practice setting. 

And what they found is that those individuals who were involved in an adverse event due to a mistake had an immediate visceral reaction, meaning immediately they felt that fight or flight response, where our sympathetic nervous system kicks into gear. And it can be all of those things that you experience when you experience anxiety and stress, which is your heart pounding, your guts churning, your breath getting more rapid, all of those different things. And that was pretty much across the board, that everyone had that immediate visceral reaction. What they also found is that there were cognitive reactions, meaning that most respondents had some sort of impairment in their concentration or in their decision-making capacity. And I don't know about you, but I know for me, when I've recognized that I've made a mistake, it just totally throws me off. 

It's like now that's just sort of bumbling in the background of my head space, and it's distracting me from what I'm trying to do. And so it makes sense then that some of these veterinarians experience this cognitive impairment. Now, what I thought was really important is when they asked the veterinarians who participated in this study what their different coping strategies were. And for the most part, veterinarians felt a desire to distract themselves, and some of them did this in healthy ways, such as with exercise or non-veterinary related activities. Others used less healthy forms of distraction, such as alcohol consumption. And one of the most common sentiments that was expressed by the veterinarians who participated was empathy.

There was this sense of real feeling for the pet owners as well as the other team members that were involved in the mistake and in the adverse event. Now, I think one of the big things to recognize as well is in this particular study, the authors seem to identify three different outcomes from individuals where some of them chose to drop out of either the spay-neuter field or the veterinary profession as a whole. Some chose to stay in the field, but they were really just surviving, meaning they were performing sufficiently, but they were still feeling traumatized by the adverse event and what had happened. And then there was a third group that was able to thrive, meaning they made peace with the event or found some sort of good in the situation. 

And they were able to let it go and move on and continue to do well at the work that they were doing. And that's what I want to springboard off of for the rest of today's episode. I want to share with you what I feel are five strategies that can help you thrive after you make a mistake, especially after that mistake leads to some sort of adverse event, some sort of patient harm. And the first of those strategies is technical learning. So, we know, based on research, that anxiety is increased in these situations by an inability to understand what went wrong and how to prevent it from happening again in the future. So, I experience all this all the time. You know, I'll have clients, coaching clients that will contact me and they'll say, "Oh, my gosh. I had this patient that was arrested under anesthesia, and I just cannot figure out what happened." And they're just replaying it over and over in their heads, trying to make sense of what happened so that they can prevent it from happening again. And of course, we don't want to get into a rumination loop where we're just replaying things over and over. But it is important to rationally and logically, after you've made it through that fight or flight initial visceral stress response, to take a step back and methodically go through what happened, try to understand why did this take place, and how can we prevent this? So, I remember going back to Lacy, just replaying over what had happened. 

The nurse that I had spoken to, what I had told her, going back to her and recognizing that she had taken the tube out and completely replaced it. Going over the fact that I was pulled in 15 different directions that day and too quickly and not methodically looked at the radiograph. The fact that there wasn't anybody reviewing that radiograph with me, you know, all of these different things. And what ultimately ended up happening in Lacy's case is that we actually created a protocol called the Lacy protocol, which is still used to this day at NC State, whereby we had a very protocolized series of steps implemented to properly place nasal feeding tubes. 

And then there was an additional rule added on that there was to be no food passed through a feeding tube until either a radiology resident or a radiologist had confirmed placement of the tube in the correct spot. And so what that did is that just took that load off of the clinician who might have been stressed, not paying attention, overwhelmed, overworked, all of these different things that can lead to mistakes and put it in the hands of someone that was trained just to do that. And that was, I think, one of the best things, or the best thing, certainly, that came out of what happened with Lacy. So, again, learning from mistakes is so important. I think every time we learn a new skill, we're going to make mistakes. The more you practice, the more you experience things, the better you will become. 

But we need to think of mistakes as steps towards improvement. So, when you do make a mistake, try to find a takeaway. Try to recognize what you need to do differently to prevent that mistake from happening again and again. This can relate to drug orders, where I've been burned before, giving people verbal drug orders. Now, I know, you know, I always write down my drugs, and when I do, I make sure if I am writing a decimal point drug dosage, that I use the leading zero before the decimal point. For example, 0.5 milligrams, I write 0.5, not just .5 without the zero, because that .5 could be mistaken as five milligrams. So, a ten times dosing difference, same thing. If I just want a five milligram dose, I don't write 5.0, I write five milligrams. Otherwise, that 5.0 could be confused as 50. 

So, just little strategies that we learn to from our mistakes. So, the second strategy that I want to share with you is the strategy of full disclosure. So, I think that we know this very strongly from the human literature, that when a mistake is made with a patient, even if no harm was caused, people want to know. And I have certainly been involved in mistakes. Again, drug miscalculations or wrong drugs given or whatever it might be, where I've disclosed this to the pet owner, thinking, "Oh, my gosh, they're going to be so angry with me. They're not going to trust me." Where it actually had the opposite impact, and it strengthened our relationship. So, we know that team dynamics, including the veterinary client relationship and team trust, are strengthened when we are honest and when we are transparent. 

So, I do think that it's important to believe that patients will benefit when mistakes are disclosed so that they can get the help that they need, and that clients will also benefit from the context of having trust and faith in the team. I do, along these same lines, think it's important to also offer to pay for any treatment that might be needed because of a mistake that gets made, whether it's hospitalization or referral to another practice or perhaps a necropsy or autopsy that might need to be done. But, you know, as simple as I can put this, there needs to be an acknowledgement of the mistake, an apology for what happened, and some sort of commitment to making sure that it doesn't happen again. And, you know, feel welcome to share that with the family. You know, "This is what's happened. We are sorry this happened, and here's what we plan to do so that this never happens again." Again, I can't stress that enough how beneficial I think that can be. The third strategy that I want to share with you in terms of thriving after a mistake that leads to an adverse event is to expand your perspective. So, I think very often we get pigeonholed into this mindset where if we make a mistake, it translates to, "I'm a bad veterinarian or I'm a bad nurse, a bad tech." That guilt about making a mistake somehow gets very quickly translated to the shame of, "I'm bad, I don't belong." Right. And I know in my situation, after I made the mistake with Lacy, I absolutely went into a shame spiral. I told myself, "I don't belong in this residency. I shouldn't be a specialist. I don't deserve to be here. I'm a bad veterinarian. I'm a bad person. I've killed this animal." And I was not taking a step back to see the context of the situation in terms of all of the animals that I had helped and would help in my career and how few I will harm along the way. So, especially for those of you who have been in practice for any period of time, try to put limits on the magnitude of the situation. For example, "The patient didn't die, or thankfully, we caught it, and now we can prevent other patients from dying." Try to see the larger context of the situation in terms of the hundreds, maybe thousands of animals that you've helped in your career and the handful of patients that you have harmed. 

I think one of the other big things that we need to remember, too, is that, and forgive me if this seems flippant or insensitive, but at the end of the day, there is more to life than the work that we do as veterinary professionals. You know, many of us are parents to animals, to family members, to human family members. We're friends, we are partners, we are teachers, we are, you know, mentors. Whatever it is that we do, there is more that we do than just help patients, and there is more to life than veterinary medicine. And so keeping things in perspective a little bit that way is really important as well. 

And if you're fortunate enough to be involved in a mistake that does result in a near miss or a harmless hit, then asking yourself, "What impact will this even have tomorrow or next week or next year? Can you let go of this sooner rather than later and focus your energy on the patients who, that you can help in future situations?" So, strategy number four is support and collegiality. So, I'm happy to say that I feel like in many practices, we are moving away from this shame and blame culture. You know, there's an adverse event, a patient dies, and it's like, "Whose fault was it? Who was in the wrong?" And this is something that I think we still need to continue to work on despite the improvement that we've seen. And ways that we can do that are to lean on each other. 

Support our friends and colleagues and coworkers when they admit that they've made a mistake, or they come to you for advice after making a mistake. Right. If yourself are looking for that support, maybe consider sharing that with a trusted person, a mentor, a coach, a friend, your boss, your manager, your coworker, someone who you trust. And maybe that's even on social media. There's actually a research study that was published in JAVMA last year in 2023, looking at the effect of disclosure and responsiveness on depression, anxiety, and compassion fatigue symptoms among veterinarians. And what they found is that the more veterinarians perceived responses to their disclosures about work-related stress as validating, understanding, and caring, the lower their levels of compassion fatigue, anxiety, and depression were. 

So, what that means is that if someone shares a story on social media that they made a mistake, the more that you can offer that care, that validation, that understanding, you know, "Been there, done that, made the mistake. Before I feel your pain," you will actually be helping that individual to recover from their distress. So, be that support. Look for that support, because we know that social support and a sense of belonging are very important during stress. And the flip side, which is that shame that "I am bad, I don't belong, I did something wrong," that is very distancing and actually exacerbates the stress. So, when you are in practice and there is a mistake that gets made, have a conversation as a group, "What happened? Can we focus on the positives? Can we find something to be grateful for? Can we share our coping strategies? What are we going to do to support ourselves and to support each other and to really avoid that shame and blame culture that we know has been prevalent in some different workplaces?" And last but not least, the fifth strategy is for emotional learning. So, this is really a recognition that ruminating on the situation is not going to serve you in the long term. Anticipate this is going to be stressful. There are going to be these visceral, cognitive, and emotional responses that you're going to have. Can you fight self-doubt and self-criticism by having the humility to know that, yes, as veterinary caregivers, we are here to help, but we also risk harming patients in the process. That is just a part of what we do. 

So, can you accept that letting go of things and moving on is what's best for everyone? And again, I'm not saying just blow it off and it's no big deal. And meh, you know, "These things happen." But to be mindful about your experience, recognize those visceral reactions, see the thoughts and feelings that are coming up for you, and then respond with self-forgiveness and self-compassion. So, I actually put together a handout a few months ago called "Self Compassion Exercises After Making a Mistake," and I'm going to link to that in the show notes. It just takes you through a meditation that I recorded, some other exercises like journaling and making a mantra that can help you, specifically in situations where you've made a mistake and you're looking for some support and self-compassion to move on. 

So, I will finish this episode off by saying that if you're listening to this in the aftermath of making a mistake yourself, hear me when I say that you will get through this. I thought after my mistake with Lacy, that I should quit veterinary medicine and never practice again. And I can tell you now, nearly two decades later, that I can confidently say that I am still practicing. And I know that I continue to have a positive impact on the lives of hundreds of patients and their families. And you will too. So, that's it for this episode of Reviving Vet Med. I hope that you took away some helpful strategies for coping in a healthy way after you make a mistake. 

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