Four-year VetSafe partnership leads to improvements in clinical care
A four-year partnership between veterinary group Linnaeus and VetSafe, the confidential significant event reporting service from the Veterinary Defence Society (VDS), has led to a range of updates in clinical care across the group’s primary care and referral centres.
VetSafe captures information about incidents or near misses in veterinary practice to encourage learning from mistakes, quality improvement and risk management.
Linnaeus started using VetSafe in 2019, with the reports submitted by its team directly leading to improvements in clinical practice. Using this insight and data, its quality improvement team has developed group-wide guidelines including an anaesthetic equipment checklist and an advice sheet for clients about giving cats pain relief.
After noting that a small number of patients had returned home with IV catheters in place, the group’s quality improvement team started a campaign for clinical teams, encouraging the use of red bandages for catheters to make them more visible. This has reduced the number of patients going home with an IV catheter, to fewer than one per month.
In 2022, nurses at Linnaeus submitted 54% of the group’s VetSafe reports and vets entered a further 35%, but all roles in practice – including client care, patient care assistants and practice managers – have used the system.
Kathrine Blackie, Quality Improvement Manager at Linnaeus, said:
“None of us intends to make mistakes, but sometimes this happens. We can be as well-trained, motivated and caring as possible but we can’t always prevent things going wrong.
“It is vital to have a culture at work that is transparent, positive and compassionate. Learning from our mistakes enables us to provide better patient care and supports the wellbeing of team members who may be affected by any errors made. We recognise that people come to work to do their best – and this includes highlighting areas for improvement.
“We are proud of everyone at Linnaeus who contributes to the reporting at VetSafe. It helps us to identify areas of risk and protect our teams and patients.”
Catherine Oxtoby, Head of Underwriting and Pricing at the VDS, and whose PhD research inspired the development of VetSafe, added:
“I hope that engaging with VetSafe helps teams turn a potentially negative situation into a positive, supported learning experience that benefits clinicians and the pets they care for.”
Linnaeus has trained VetSafe champions in every practice across its network. The champion encourages colleagues to submit reports and is automatically notified when an incident is submitted. They review the report to understand what has happened without blame, and identify how to make improvements. The quality improvement team at Linnaeus reviews all VetSafe reports to identify wider trends and provide the evidence for changes, new training or guidelines. Being part of Mars Veterinary Health means learning can be shared across an even wider scale to improve patient care.
Every Linnaeus practice must also prove they have a no-blame culture for reporting errors. The Clinical Director at each site is asked to sign a Just Culture pledge; its principles include ensuring people are not judged or punished for making a mistake. The pledge is displayed as a show of commitment to the principles.
Iain Fletcher, Clinical Director at Spinney Vets in Northampton, commented:
“VetSafe is an invaluable way of encouraging Associates to report both clinical and non-clinical issues and improve our quality of care. We have strong engagement with VetSafe but it’s important to constantly remind and encourage colleagues to use this vital system.
“At Spinney Vets, we have found that careful reviewing all reports is essential; sometimes incidents require an immediate change of process, but others may require a more prolonged audit. We have created an audit spreadsheet for commonly reported problems to track whether a change is needed – and if we have updated a process, how successful this has been. In particular, VetSafe has helped us to improve our approach to surgical site infections and antibiotic stewardship.”
Emma Dever, Head of Nursing Services at Kentdale Referrals in Cumbria, said:
“VetSafe reporting is now an embedded practice at Kentdale, with any near-misses or incidents submitted in confidence. By reviewing problems caused by human error, we have been able to implement processes and procedures to prevent them occurring again, helping us to deliver the best possible care to our patients.
“Increased training in specific areas, changes to dispensing processes by enhancing medication labels and creation of new checklists are just some of the changes introduced as a result of VetSafe reporting. This has benefited both our patients and the team, as no one intends to make a mistake.”
For further information about clinical quality at Linnaeus, please visit www.linnaeusgroup.co.uk/medical-and-nursing/clinical-quality.