Learning from mistakes: VetSurgeon M&M Forum

RE: Learning from mistakes: VetSurgeon M&M Forum

vetbl.locum — Thu, 19 Jan 2017 21:16:01 GMT

Arlo

CHIRP for Aviation = Confidential Human Factors Incident Reporting Programme

Sorry for late reply

If you could set up a vet one that be great!

but need lots of time and money

I believe you report your concerns to CHIRP and they remove the identity of poster

Surely with no tolerance of blame culture , we having nothing to fear from RCVS! ;-)

RE: Learning from mistakes: VetSurgeon M&M Forum

Anthony Todd — Thu, 19 Jan 2017 14:17:46 GMT

Um, being an outspoken dinovet ,can you show me how to post anonymously, and it might be me who posts a good one....

We can test the technology with innocuous examples, or silly ones, first.

You could call the thread NoBLE?

RE: Learning from mistakes: VetSurgeon M&M Forum

Arlo Guthrie — Thu, 19 Jan 2017 14:05:14 GMT

[quote user="Braden Collins"]I really like the idea Arlo, but I think the key is always going to be overcoming the fear that discussing mistakes on here could lead to problems with the RCVS or other organisation if we admit an error. The anonymous function could obviouly help that, so is there a way that an inital post could automatically be anonymous within a section of the forum? It would make it easier for the less frequent users to put forward their cases.[/quote]

I agree Braden. I suppose the first thing that comes to mind is that the degree of anonymity required is probably a function of the size or frequency of the mistake(s)!

At the moment, anonymity for that first post (or indeed any subsequent ones) in the forum is provided with the anonymous login.

I think regardless of the final format of this, we'd probably need to continue with that methodology, because if we allowed a logged a member logged in under their own account to post anonymously, then there would be a direct record in our system that they had done so. It wouldn't be visible publicly, but I think it would be better if it didn't exist at all!

Better to have a separate, genuinely anonymous account as we do now, which makes it nigh on impossible for anyone to know who posted.

RE: Learning from mistakes: VetSurgeon M&M Forum

Braden Collins — Thu, 19 Jan 2017 13:41:23 GMT

I really like the idea Arlo, but I think the key is always going to be overcoming the fear that discussing mistakes on here could lead to problems with the RCVS or other organisation if we admit an error. The anonymous function could obviouly help that, so is there a way that an inital post could automatically be anonymous within a section of the forum? It would make it easier for the less frequent users to put forward their cases.

RE: Learning from mistakes: VetSurgeon M&M Forum

Francisco Gomez — Thu, 19 Jan 2017 11:37:31 GMT

[quote user="Arlo Guthrie"]

Er, my 'why' was 'why for vets', and I assumed that the positive response to my 'why' was that those who responded agreed.

But maybe I'm assuming too much, so OK, JGW:

Danny Chambers, Eilidh Corr, Francisco Gomez, Kate Richardson, Hannah Wynne Richards, Alan Robinson, Dinu Catilina, Joyce Whitehead, Noweia, Anthony Todd, Jo Dyer, Clare Tapsfield-Wright, janine redman and Malcolm Ness ....

You've all either 'liked' the original post, or commented favourably, or said there might be something in it.

So let me ask what YOU think are the benefits of sharing and discussing errors, and developing ideas for avoiding a repetition? Either for you personally, or in terms of what (if any) impact you think it could have on the broader profession / animal welfare etc.

[/quote]

Sorry for the delay Mr. Speaker! been slighly busy last couple of days.

At risk of repetition, as right now I don't have the time to read the whole thread since I left it, I feel that a blame-free open discussion is beneficial. and I agree VDS input here is likely to be not just advisable but perhaps we should think mandatory. I.e. we shouldn't agree on a course of action and give advice without a supporting body, in case we all agree to something that wouldn't stand in a litigation case.

The VDS letter about cases is really good, but it lacks the dynamics of a forum like this. It is much more useful, in my opinion, showing a case where you can dig and ask about potential scenarios or deviations from the original case rather than just 'taking it as it comes' as the way the VDS letter does, which is again very useful, but restrictive and more 'dictatorial' as per you don't have the tools to make a constructive critic where the same people who read the original post can read the answers of the potential contributors.

RE: Learning from mistakes: VetSurgeon M&M Forum

Hannah Wynne Richards — Thu, 19 Jan 2017 09:59:18 GMT

Another problem with subdividing is that the sharing will be more repetitive, and therefore less helpful. New grads can teach us dinovets the latest theories, and we can teach them experience based medicine.

Wynne

RE: Learning from mistakes: VetSurgeon M&M Forum

Arlo Guthrie — Thu, 19 Jan 2017 09:38:34 GMT

[quote user="Glen McIntosh"]The human medics are a fair bit ahead of us in terms of M & M s, they've been doing them for years. It got me wondering if they have done anything similar to what Arlo is suggesting. [/quote]

Glen McIntosh THANK YOU for such a thoughtful and helpful post. I hadn't seen that US website. The 'submit case' seems to represent a very good starting point (at first glance, I thought the one way to improve it would be to ask the submitter to categorise).

[quote user="Glen McIntosh"]Alternatively, vet surgeon.org could be the platform that facilitates online m and m rounds for smaller, closed, by invitation only, groups (e.g. larger gp groups, corporates, new grads, dino vets etc) that have a collective caseload that could sustain m and m rounds[/quote]

Yup, that too. My only fear is that you need a lot of members of each group to provide enough raw material.

RE: Learning from mistakes: VetSurgeon M&M Forum

Arlo Guthrie — Thu, 19 Jan 2017 09:30:23 GMT

[quote user="Anthony Todd"]Just beat me too it! They'll be "distressed" when they have to defend, and pay for, a case hinging on some post in the NoBLE thread.......[/quote]

A couple of people have mentioned this worry about the risk of an error being posted online then coming back to haunt them in court.

The current setup is that when people use the anonymous account to post, nobody, including me, knows who posted it. It is therefore very hard to imagine how a post made under the anonymous account would ever be admissible in court (though to be 100% sure, I am taking advice on this).

For those interested in the technical explanation of that statement:

When someone posts on the site, there is a record of the purported IP address of the computer used to post. But that doesn't tie the post to a person for the following reasons:

a) I say 'purported'; IP addresses can be spoofed (ie someone can set their computer to appear to be posting from an IP address which 'belongs' to another machine / network). So there is no guarantee that a post which says it came from a particular IP actually did.

b) In any event, IP addresses are the address of a computer, not a person. Many computers have (or could have) multiple users.

c) Most residential IPs are what are called 'dynamic', which means they are assigned by a service provider from a large pool of IPs, and they change each time you reconnect to the Internet. So to know precisely which machine (not person) purported to have made the post, one would need not just a court order to get VetSurgeon to surrender the IP address, but a court order on the service provider too (and even then, one wouldn't know 'who' posted; just the computer that might have done).

So, whilst security agencies might go to these sorts of lengths to investigate terrorism, the risk of an anonymous post being used in a civil court seem infinitesimally small to me. Particularly in relation to an error/accident involving an animal.

RE: Learning from mistakes: VetSurgeon M&M Forum

Anthony Todd — Wed, 18 Jan 2017 23:11:09 GMT

[quote user="Braden Collins"]Could the VDS be involved in the forum directly? If they could be invited to join the NOBLE part of the forum we could all benefit from their advice, and for them it would be great marresting plus a way to potentially reduce claims. [/quote]

Just beat me too it! They'll be "distressed" when they have to defend, and pay for, a case hinging on some post in the NoBLE thread.......

Be suicidal not to involve them in any public or accessible source of veterinary mistakes.

RE: Learning from mistakes: VetSurgeon M&M Forum

Anthony Todd — Wed, 18 Jan 2017 23:03:53 GMT

[quote user="Kate Richardson"]a[/quote]

gotta reply

z, on principle, seeing it's you......

RE: Learning from mistakes: VetSurgeon M&M Forum

Kate Richardson — Wed, 18 Jan 2017 22:41:24 GMT

RE: Learning from mistakes: VetSurgeon M&M Forum

Braden Collins — Wed, 18 Jan 2017 22:15:03 GMT

Could the VDS be involved in the forum directly? If they could be invited to join the NOBLE part of the forum we could all benefit from their advice, and for them it would be great marresting plus a way to potentially reduce claims.

RE: Learning from mistakes: VetSurgeon M&M Forum

Glen McIntosh — Wed, 18 Jan 2017 21:47:08 GMT

The human medics are a fair bit ahead of us in terms of M & M s, they've been doing them for years. It got me wondering if they have done anything similar to what Arlo is suggesting. A pretty superficial google search produced only one demonstrably online human M and M rounds. It is run by the US government:

https://psnet.ahrq.gov/webmm

It is actually pretty good, completely open for public viewing, but not a forum. The cases are briefly described and then given a commentary by experts in the appropriate field. The case submission page may be helpful for the vet surgeon.org project:

https://psnet.ahrq.gov/webmm/submit-case

All the cases are carefully anonymised. But even so, if US doctors, who practice in the most litigious country in the world, are willing to put this sort of stuff out there in the public domain, on a website run by the US government - no less - it would seem that vet surgeon.org M and M online rounds, displayed on a reasonably exclusive and password protected website, is on pretty safe legal grounds, provided all submissions are strictly anonymised.

So why aren't there any online forum type M and M rounds like the one that is proposed by Arlo, already up and running for human medics? I can't believe that it hasn't been thought of before. Of course we wouldn't be able to access them directly, but there would surely be lots of studies demonstrating efficacy or otherwise if such things existed. Maybe there are but there are none that I could find.

My guess is that there is no great need for that type of M and M format in human medicine. It is always going to be far better to do M and M rounds in real time and face to face in a closed and strictly confidential setting so that very specific case detail can be discussed. Pretty much all medical practitioners working in hospitals will be exposed to this, perhaps compulsorily. In these large institutions the participants of M and M rounds would be exposed to a wide and varied caseload.

In the veterinary world, except for those working in universities and private referral institutions and possibly a few of the larger GP practices, most vets will never get exposure to M and M rounds of the breadth seen in human hospitals.

Yet most vets ARE practicing in a hospital environment, performing surgeries and other procedures that expose patients to human error with potential life threatening consequences. But on a much smaller scale in comparison to human medical practice. A single, average, 2 or 3 man veterinary practice might never see a specific type of error that causes a significant morbidity or mortality in 30 years of operations, say. Or it might see it once every 30 years. But somewhere in a collective of 100 (or 1000) 2 or 3 man practices, that error might occur on average once every 4 months (or once every 10 days). The example of the hot water bottle burn injury given above is a good example. I work in a 30 vet referral practice and it was only in the last 2 years that we stopped using hot water bottles because of a burn injury (the practice has been using hot water bottles for warming for 15 + years prior to this without incident).

Arlo's proposal may be the best approximation of regular, face to face, real time M and M meetings that many of us will get. The potential benefits seem to clearly outweigh the risks and Arlo's proposal has the potential to facilitate this sort of collective M and M rounds, and the potential size of the collective will make it all the more powerful.

Alternatively, vet surgeon.org could be the platform that facilitates online m and m rounds for smaller, closed, by invitation only, groups (e.g. larger gp groups, corporates, new grads, dino vets etc) that have a collective caseload that could sustain m and m rounds but geographically unable to run regular, in person, m and m rounds that large single site institutions can.

RE: Learning from mistakes: VetSurgeon M&M Forum

Eilidh Corr — Wed, 18 Jan 2017 18:46:53 GMT

In principle I think it's got the potential to be really valuable. I agree that it might be prudent to check with the VDS and I think a way of truly anonymising cases for discussion is essential.

Mistakes are a fact of life but it's easy to look around at seemingly perfect peers and feel that you're the only one to make them. If we as a profession talked more about them then maybe they would become less common - after all, if nobody discusses a really common mistake then it's easy to feel that it's actually really rare and unlikely. Our practice experienced this recently with a hot water bottle burn - we've used them for literally decades and never had an issue. It's become very apparent that burns from them genuinely aren't uncommon. Maybe we'd have been more careful if any of the staff involved had some previous experience or knowledge of burns arising from warming methods. We've certainly completely altered our approach to maintaining patient temperatures now (with emphasis on the maintenance!) but I wish it had never happened. I think (hope) we were constructive rather than critical of the nurses and we sat down with them all and agreed a new protocol together without any apportioning of blame.

On that note, my main concern would be that this forum can see some very, um, robust responses and I think it would need to be a judgement-free zone, preferably posts being pre-approved before publishing. This creates a huge moderation burden but if the submitting vet is already in an anguished frame of mind then there's a responsibility not to be unduly harsh and critical.

Sorry most of that was an incoherent ramble but I'm posting from my phone and it's a PITA to edit

RE: Learning from mistakes: VetSurgeon M&M Forum

Hannah Wynne Richards — Wed, 18 Jan 2017 15:12:41 GMT

You may find it hard to believe, because I've toughened up a lot, but I was dreadfully insecure when I was a new grad. Senior colleagues were supportive, but those a couple of years qualified saw me as a natural victim, and boosted their own inadequacies by sneering at me in front of support staff. A forum like this where I could ask advice anonymously would have been a godsend when I was bullied.

Wynne

RE: Learning from mistakes: VetSurgeon M&M Forum

Joyce Whitehead — Wed, 18 Jan 2017 14:30:10 GMT

Personally I feel that finding out that others have made the same mistake is reassuring, and I've learned things I will be wary of in future too (prostate removal instead of undescended testicle springs to mind). I think no honest vet could think they had never made an error in their career, however minor, and sharing in a supportive environment is surely the place to be. I think Malcolm's advice to speak to VDS is sensible, as I would hate to see a forum post being quoted in court.

I am lucky to have worked in our own practice for many years but have worked when younger in places with very little support from senior colleagues. In those days, having something like this would have been a godsend.

RE: Learning from mistakes: VetSurgeon M&M Forum

Clare Tapsfield-Wright — Wed, 18 Jan 2017 12:43:06 GMT

I still think it's a great idea. Anything that gives vets a chance to consult their colleagues without repercussions and learn from mistakes or near misses is probably the best sort of CPD there is.

The positive benefit on this site for previous anon posters who have made a mistake and needed support and advice has been its immediacy and lack of formality so involving official bodies and hurdles to jump through might just kill it dead in the water. It often seems to be self criticism worry and fear making the OP reach out to colleagues on the list. The subsequent discussion and help is likely both supportive and educational for more vets than just the poor sod who has made an error.

how about an anonymous pilot scheme , you should be brilliant at pilot schemes Arlo

RE: Learning from mistakes: VetSurgeon M&M Forum

Arlo Guthrie — Wed, 18 Jan 2017 12:05:43 GMT

[quote user="Anthony Todd"]Yes, your own are much more memorable and other's mistakes are always ones you [or I] would never make; ever so might be forgotten for that reason?[/quote]

Thinking back to my days as a commercial pilot, reading about the mistakes of others. I think that even where my immediate thought was 'I would never have done that', I still took something from it, because however much I might think or say 'I would never have done that', there are circumstances under which I might. And when presented with those circumstances, that report I read a while back would trigger an alarm bell.

I'm trying to think of an example. I can't think of a specific, but there are lots of crash reports involving a pilot's decision to exceed their ability in poor weather. Sure, the most memorable lesson for me was when I did it myself. And I would read crash reports involving poor weather and think: 'it'd never happen to me'. But reading those reports reinforced the point. They fed into my decision-making process. Constructively, I believe.

RE: Learning from mistakes: VetSurgeon M&M Forum

Anthony Todd — Wed, 18 Jan 2017 11:53:26 GMT

[quote user="Dinu Catilina"]The main benefit I see is for new graduates to understand that mistakes will be made and it will not be the end of the world as they know it. I for one find it hard to always learn from the mistakes of others but learned very fast from my own. [/quote]

Yes, your own are much more memorable and other's mistakes are always ones you [or I] would never make; ever so might be forgotten for that reason?

RE: Learning from mistakes: VetSurgeon M&M Forum

Dinu Catilina — Wed, 18 Jan 2017 11:49:56 GMT

[quote user="Arlo Guthrie"]So let me ask what YOU think are the benefits of sharing and discussing errors, and developing ideas for avoiding a repetition? [/quote]

The main benefit I see is for new graduates to understand that mistakes will be made and it will not be the end of the world as they know it. I for one find it hard to always learn from the mistakes of others but learned very fast from my own.

RE: Learning from mistakes: VetSurgeon M&M Forum

Anthony Todd — Wed, 18 Jan 2017 10:49:10 GMT

[quote user="Arlo Guthrie"]So let me ask what YOU think are the benefits of sharing and discussing errors, and developing ideas for avoiding a repetition? Either for you personally, or in terms of what (if any) impact you think it could have on the broader profession / animal welfare etc[/quote]

All for it!

Just another one... "Experience" is when you realise you've made the same mistake again"

or topically "I just avoided the mistake that someone made before me, and I read about"

RE: Learning from mistakes: VetSurgeon M&M Forum

Arlo Guthrie — Wed, 18 Jan 2017 09:45:28 GMT

[quote user="John Flynn"]Small discussion groups of like minded peers[/quote]

That also is another way of skinning the cat - ie that a discussion forum is limited to personally invited and verified individuals and grows in line with people's comfort levels in discussing mistakes (if that makes sense).

[quote user="J G Wray"][quote user="Arlo Guthrie"]Confused - I thought I had already explained 'Why'.[/quote]Why for you maybe, but how about why for vets[/quote]

Er, my 'why' was 'why for vets', and I assumed that the positive response to my 'why' was that those who responded agreed.

But maybe I'm assuming too much, so OK, JGW:

You've all either 'liked' the original post, or commented favourably, or said there might be something in it.

RE: Learning from mistakes: VetSurgeon M&M Forum

John Flynn — Tue, 17 Jan 2017 20:14:37 GMT

i expressed my views in previous thread and i re-read them and they're the same now.

in a nut shell: sharing mistakes or discussions of cases with poor outcomes can be very educational but needs done away from prying eyes. Small discussion groups of like minded peers, and/or a good moderator are probably keys to success.

RE: Learning from mistakes: VetSurgeon M&M Forum

Anthony Todd — Tue, 17 Jan 2017 19:20:41 GMT

[quote user="Thomas Johnson"]http://www.rcvs.org.uk/news-and-events/news/rcvs-and-bva-launch-vet-futures-initiative/[/quote]

Well I read this, or at least the first page, or some of it, and it reminds me of a picture of a sunset; worthy, beyond criticism, limitless, beyond boundaries, lovely, but that's it!

PS, forgot "panoramic".....

Love to hear other opinions!

RE: Learning from mistakes: VetSurgeon M&M Forum

Anthony Todd — Tue, 17 Jan 2017 19:10:56 GMT

[quote user="Jill Butterworth"]I saw some pretty bad things that wouldn't happen now...hopefully...[/quote]

Just a few anonymous examples would help because I don't think I, or other dinovets, did bad things then that now don't happen now.

I mean 3 full bloods on the day of a pyo recently springs to mind.....