Incidents and Accidents

RE: Incidents and Accidents

Anthony Todd — Thu, 09 Jun 2016 19:34:42 GMT

[quote user="Bob Russell"]We learned little about Chikosi (even after reading the full DC file)[/quote]

Well apart from the circumstances of the injury to the dog, the damage to the building, the over-reaction of the farmer and his son etc.

Without all that and all the other evidence and anecdote there could be no defence or sympathy at all.

I'm not saying the decision was wrong, but the anecdotal supplementary evidence explained the decision and the leanings of the DC.

Together with the subsequent actions of Mr Chikosi it puts a somewhat different light on the affair.

How often do we hear "but that's not the whole story"?

That's why the anecdote and circumstances are important in this present thread.

RE: Incidents and Accidents

Hannah Wynne Richards — Thu, 09 Jun 2016 17:42:15 GMT

Anthony You're absolutely right - when you say that anecdote it must be. I don't do much rabbit surgery. I once lost a rabbit under routine anaesthesia (spay)

I had given ketamine/medetomidine at the rate recomended in BSAVAs Manual of small animal anaesthesia and analgesia (1999) which was 25 mgs/kg ket and 0.5 mgs/kg med. I then checked on BSAVAs Manual of rabbit medicine and surgery (2000). This recomended 15mgs/kg ket and 0.25 mgs/kg med. I haven't lost a rabbit since changing.

It would be no help to anyone else if I just said I'd lost a rabbit from overdosing - after all, that might just mean I hadn't bothered to weigh!

Wynne

RE: Incidents and Accidents

Martin Atkinson — Thu, 09 Jun 2016 17:11:36 GMT

[quote user="Bob Russell"]

Definition of sanction - "a threatened penalty for disobeying a rule or law"

Synonyms: Penalty, punishment, deterrent ..

The threat of the DC might be sanctioning but striking off is definitely punishment!

The purpose of regulation is to keep things in check but punishment, under the guise of protecting the public, is there!

[/quote]Synonyms are not definitions. There are occasions when a punishment may be a sanction but not vice-versa. I prefer the definition: 'A means of encouraging adherence to a social custom'.

If you are struck off it is not a punishment for you but as you have iterated to protect patients/clients and to protect the reputation of the profession from your inability to perform your work to a reasonable standard and to allow you time to reeducate/rehabilitate yourself. You are being prevented from doing further harm. I don't think the DC ever sets out to do anything other than ultimately make you improve your standard of work/care so you can be rehabilitated.

If you received a custodial sentence or fine for the incident/offence which got you struck off - that is the punishment. Although I suspect striking off Chikosi was pretty close to a punishment for cocking a snook at them.

RE: Incidents and Accidents

Bob Russell — Tue, 07 Jun 2016 15:48:17 GMT

We learned little about Chikosi (even after reading the full DC file). He said nothing, defended nothing, instead he travelled home.

What we did learn was that the DC could be extremely flawed and some comments that were made (as pearls of wisdom) were actually a load of cr+p. Clearly comments made by individuals unsuited to the job of judging their peers and daft enough to be quoted!

I cannot think of a single DC case since that has been carried out with anything like the incompetence of Chikosi. This suggests a long and careful think about what they do and say.

It was the idea that a sound clinician might be judged by a group of clowns that frightened the profession (IMO!).

RE: Incidents and Accidents

Anthony Todd — Tue, 07 Jun 2016 13:22:36 GMT

[quote user="vetbl.locum"]He was not a dick but working hard in a difficult environment in a busy area with limited resources Sounds very like vet practice!! [/quote]

You make my points well!

RE: Incidents and Accidents

vetbl.locum — Tue, 07 Jun 2016 12:57:06 GMT

Anthony

He was not a dick but working hard in a difficult environment in a busy area with limited resources Sounds very like vet practice!!

Lots of traps and the holes in swiss cheese ( error model) lined up that day and got him

But yes we need a THREAT ERROR MANAGEMENT thread to discuss events in practice. Thus the anon vet says i 'f**k*D up ' does not help anyone and serves only as a request for a hug (however well deserved)

Questions is : Why the holes lined up for that anon vet and that dog on that day ?

Then we all could use this dreadful event to prevent further dreadful events !

Yes back to your example : Why have doses in micrograms/kg and solutions as 10mg/2mls Just making error holes Decimal points misread Phone app calculator slavishly believed

Rgds

RE: Incidents and Accidents

grumpyoldman — Tue, 07 Jun 2016 12:56:19 GMT

[quote user="J G Wray"]Its profound weakness is vexatious and frivolous complaints.[/quote]

One of them , the other is giving them two bites at the cherry and a chance to morph niggling,whinging and trying to wriggle out of paying a bill into some kind of conduct issue.

Far better to write to MPs ,or email them ,asking for a judicial review of the whole thing. Particularly the malicious and vexatious complaints, where they are just clearly evil monsters. Every client and every sperm are not sacred and this needs recognising.

RE: Incidents and Accidents

vetbl.locum — Tue, 07 Jun 2016 12:40:36 GMT

[quote user="Anthony Todd"]

[quote user="vetbl.locum"]Pprunes post accident discussions which rapidly degenerate into chaos[/quote]

And my, don't the good guys on there quickly jump on the morons and trolls, so I don't think that reason would apply.

The old red star or single yellow induces reflection!

[/quote]

Sometimes

The Shoreham crash thread was not pleasant

There good guys did jump on trolls but sadly thet did have a valid point even if badly put

Similarly the gnat crash thread

RE: Incidents and Accidents

Anthony Todd — Tue, 07 Jun 2016 12:28:01 GMT

[quote user="vetbl.locum"]Pprunes post accident discussions which rapidly degenerate into chaos[/quote]

And my, don't the good guys on there quickly jump on the morons and trolls, so I don't think that reason would apply.

The old red star or single yellow induces reflection!

RE: Incidents and Accidents

Anthony Todd — Tue, 07 Jun 2016 12:23:20 GMT

[quote user="vetbl.locum"]ask my colleague done for busting London Stanstead's control zone ...twice!! [/quote]

Ah, an excellent example of why we should have an "error" section [??separate password protected?.]

If your colleague had added an anecdote or explanation, which may or may not be prevention relevant, other pilots may benefit.

[ see my exaggerated example of the dose-rate decimal point....]

If he was just a dick or wasn't competent then silence from him would be revealing..

Remember Chikosi, where would he be without the emergent story!

As has been said many times in the related thread, if we had the anecdote or story we may understand, support, sympathise, advise and probably learn something.

At the moment sympathy is all we can offer.

RE: Incidents and Accidents

vetbl.locum — Tue, 07 Jun 2016 11:57:11 GMT

Arlo

CHIRPS is a good starting point but would require a lot of work It is similar to VDS newsletter tales but is good to see CHIRP's reasoned response to poster's article

I do not think posting a case here and the ensuing bun fight would be useful It would be like Pprunes post accident discussions which rapidly degenerate into chaos

CAA is involved punishment of pilots -- ask my colleague done for busting London Stanstead's control zone ...twice!!

RE: Incidents and Accidents

Bob Russell — Tue, 07 Jun 2016 10:56:22 GMT

Definition of sanction - "a threatened penalty for disobeying a rule or law"

Synonyms: Penalty, punishment, deterrent ..

The threat of the DC might be sanctioning but striking off is definitely punishment!

The purpose of regulation is to keep things in check but punishment, under the guise of protecting the public, is there!

RE: Incidents and Accidents

J G Wray — Tue, 07 Jun 2016 10:30:10 GMT

[quote user="Jo Dyer"]

There are lots of books about it, I'm reading Black Box Thinking by Matthew Syed at the moment which is a very readable summary of the concept. There's this TED talk, which I've mentioned before;

https://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that

And books like 'Second victim', 'Just Culture' and 'Understanding human error' by Sidney Dekker, along with most books by Atul Gawande such as 'Complications' and 'The Checklist Manifesto'.

[/quote]

Q1 And what's everyone else at RCVS reading and saying and then doing?

Q2 This isn't in Vet Futures, so it can't be for vets. Who else might this be for?

RE: Incidents and Accidents

Neil Wheadon — Tue, 07 Jun 2016 10:19:27 GMT

I don't feel this forum is a place for this

Few people will contribute and if they do, the replies may not be that constructive. I'd think twice if not 10 times before posting anything on a public forum.

I would far rather efforts were put into 'Case of the month' something simple like a polydipsic dog or a radiograph (with an answer posted later) and something we can learn from with people chipping in ideas. This forum could be an amazing resource and that would help push it along

Neil

RE: Incidents and Accidents

Anthony Todd — Tue, 07 Jun 2016 09:43:41 GMT

[quote user="Iain Richards"] It has to be foramlised, optherwise it's just anecdote[/quote]

"Just anecdote" is exactly what it must be!

The important thing about "incident " reporting is the anecdote that goes with it, ie the reason why. AAIB reports are loaded with them.

"I gave a dose 10 times the dose of anaesthetic" doesn't help much, but if I added "because the dose given on XXXX.co.uk has the decimal point in the wrong place [to take a stupid but illustrative answer] then it is likely that folk will check quoted dose rates more carefully.

The purpose is not redemption or confessional but future prevention.

RE: Incidents and Accidents

Jo Dyer — Tue, 07 Jun 2016 09:29:20 GMT

[quote user="Arlo Guthrie"]What ever form or shape it took, it would have to be completely divorced from any kind of disciplinary process.[/quote]

Yes I agree of course. If there is the slightest risk of sanction, any chance of getting useful information regarding the incident disappears - e.g. the Glasgow lorry driver who was giving evidence to the enquiry, but dried up immediately when civil proceedings were instigated.

What I mean is, the profession can adopt a 'no-blame' culture e.g. via a system such as you are proposing, but there are still going to be a very small number of vets who, for whatever reason, pose a risk to the public and their animals, therefore a disciplinary process needs to be available from a completely different organisation, with no crossover of information.

RE: Incidents and Accidents

Arlo Guthrie — Tue, 07 Jun 2016 09:17:30 GMT

[quote user="Jo Dyer"]I know it seems like a contradiction in terms but I assume that even in aviation, with its brilliant 'no-blame' culture and accident/near-miss reporting which has made it the safe industry it is today, pilots still get disciplined if they are a risk to the public. It can be done.[/quote]

AFAIK, the CAA does not have a disciplinary function. It simply grants pilots licences on the basis that applicants meet medical and training standards.

For example, see this response from the CAA to the question of drunk pilots (a matter which you would think representative of the most serious professional misconduct):

https://www.caa.co.uk/WorkArea/DownloadAsset.aspx?id=4294970528

Disciplinary matters are handled by the employer or by the police.

This is another reason why (to my mind) any incidents and accidents structure in the veterinary profession could not be administered by the RCVS. What ever form or shape it took, it would have to be completely divorced from any kind of disciplinary process.

RE: Incidents and Accidents

Arlo Guthrie — Tue, 07 Jun 2016 07:59:52 GMT

Done some more research into incident and accident reporting in the aviation industry (because I think it sets a standard in terms of how these things are done, and it's been 20 years since I was a pilot and things have moved along a bit since then).

There are various ways in which incidents and accidents in aviation are reported.

Mandatory Occurence Reporting Scheme (MORS):
By law, it is mandatory to report certain types of aviation incident, through this system.
Aviation and Maritime Confidential Incident Reporting (CHIRP)
A charitable organisation which provides a supplementary reporting system.
AAIB Accident Reports
When an accident is investigated, the results are published by the AAIB.

First thing that strikes me is that it'd be very valuable to talk to these organisations to get a better understanding and see what can be learned from them.

Other things that immediately come to mind are:

There's no legal requirement to report veterinary incidents/accidents (and nor should there be), which limits the data that can be collected in the veterinary profession.
I think (and it has been a while) that the CAA is perceived very differently by pilots than the RCVS is perceived by vets. I think (just my perception), that the CAA is not feared in the same way. I think it is trusted more (essentially because it doesn't regulate on behalf of a complaining public, but in the interests of safety). I mention this because I think in the veterinary profession, trust in the organisation that administers a reporting system would be absolutely paramount.
As in the aviation industry, a reporting scheme could be run at different levels (ie from at its most simple, an informal, pre-moderated, secure forum here, to a more complex system which allows for greater data analysis / reporting).
At first glance, the CHIRP model seems to me to be the most applicable to the veterinary profession.
Essential components: Anonymity. Trust (in the organisation handling the data). Security (ie how and with whom reports / resultant data is shared).

RE: Incidents and Accidents

Jo Dyer — Tue, 07 Jun 2016 07:38:51 GMT

[quote user="Arlo Guthrie"]I'm thinking how we could develop this into a more formal (or rather, 'slightly less casual') incident reporting system.[/quote]

I think it's a great idea Arlo, and I love the name 'VIRuS'

We need to get vets talking about mistakes and near-misses in a way that removes the stigma and makes them a learning opportunity. It could take some time but this would be a start, with the protection of anonymity of course.

Clinical governance is in the PSS and part of that involves talking about these things and learning from them. But first there has to be a situation where people know they will not be judged for getting something wrong in a non-anonymous situation, and that will really take time.

There are lots of books about it, I'm reading Black Box Thinking by Matthew Syed at the moment which is a very readable summary of the concept. There's this TED talk, which I've mentioned before;

https://www.ted.com/talks/brian_goldman_doctors_make_mistakes_can_we_talk_about_that

And books like 'Second victim', 'Just Culture' and 'Understanding human error' by Sidney Dekker, along with most books by Atul Gawande such as 'Complications' and 'The Checklist Manifesto'.

[quote user="Bob Russell"]How can a regulator create a no blame culture? The purpose of a regulator is to apportion blame and 'punish' as appropriate.[/quote]

I know it seems like a contradiction in terms but I assume that even in aviation, with its brilliant 'no-blame' culture and accident/near-miss reporting which has made it the safe industry it is today, pilots still get disciplined if they are a risk to the public. It can be done.

[quote user="Francisco Gomez"]I see things coming into this just because they are 'extraordinary' not because they are 'likely'.[/quote]

Which is exactly why it's important to report everything, small errors and near-misses which never caused a problem, but might have.

[quote user="Evelyn Barbour-Hill"]As I understand it (might have got it all wrong of course) the "no blame culture" means making the vet pay compensation whenever there is dissatisfaction, whether the vet is to blame or not.[/quote]

Nope

RE: Incidents and Accidents

J G Wray — Tue, 07 Jun 2016 07:38:27 GMT

Kind of. There is a route to this, a mechanism, which other regulators have followed as best practice, or first rate practice if you like and that is adopting an "outcome focused" stance on regulation (OFR).

http://www.sra.org.uk/solicitors/handbook/handbookprinciples/content.page

Because there is a "corporate" regulatory feel to this, something RCVS craves, the pretext of ~"no blame" will be our first rate regulators trojan horse.

In OFR, not only are you expected to correct any complaint but the starting point is one of failure since by definition a client have suffered failure for a complaint to be made.....Its profound weakness is vexatious and frivolous complaints.

RE: Incidents and Accidents

J G Wray — Tue, 07 Jun 2016 07:30:35 GMT

[quote user="Gillian Mostyn"]I didn't think 'punishment' was their objective[/quote]

Perrrrrlease. It is the outcome and only those with a capacity to utterly objectify what they do can ignore the punitive element or a DC ruling.

RE: Incidents and Accidents

Evelyn Barbour-Hill — Tue, 07 Jun 2016 00:37:32 GMT

[quote user="Gillian Mostyn"]I thought it was to investigate any claims of negligence made by the public[/quote]

I hope that "negligence" was a misprint for "professional misconduct", Gillian.

[quote user="Gillian Mostyn"] I didn't think 'punishment' was their objective?[/quote]

But you are quite right there.

Nonetheless a striking-off or suspension is going to have the effect of a punishment.

[quote user="Bob Russell"]How can a regulator create a no blame culture?[/quote]

As I understand it (might have got it all wrong of course) the "no blame culture" means making the vet pay compensation whenever there is dissatisfaction, whether the vet is to blame or not.

RE: Incidents and Accidents

Francisco Gomez — Mon, 06 Jun 2016 23:13:50 GMT

I like the idea in principle. But if the aim is about learning of other people mistakes, we run the risk of giving these 'published' mistakes more value or a higher profile than more common ones. I see things coming into this just because they are 'extraordinary' not because they are 'likely'.

RE: Incidents and Accidents

Gillian Mostyn — Mon, 06 Jun 2016 22:43:39 GMT

[quote user="Bob Russell"]The purpose of a regulator is to apportion blame and 'punish' as appropriate.[/quote]

I thought it was to investigate any claims of negligence made by the public, and impose any sanction on the VS/RVN that they feel necessary to safeguard animal welfare and maintain the confidence of the public. I didn't think 'punishment' was their objective?

RE: Incidents and Accidents

Bob Russell — Mon, 06 Jun 2016 12:57:54 GMT

The RCVS will have access to VDS News but I very much doubt they have any access to VDS reports! They will be confidential and between VDS and the member involved!

I suspect this is what you meant but all member contact with VDS is confidential!!

How can a regulator create a no blame culture? The purpose of a regulator is to apportion blame and 'punish' as appropriate.

I can see nothing wrong with an independent reporting process to build up a picture of mistakes/errors etc but only under the control of a trusted third party.