How right I was on implementing checklists in a veterinary practice as described in my last post. The Boston Globe today (June 30, 2009) reported that the Rhode Island Hospital Association has had agreements from all 14 hospitals in the state that they will voluntarily comply with a new set of surgical standards and protocols. It seems that Miriam Hospital in Rhode Island reported a “near-miss” in it’s voluntary state reporting of medical errors when a surgeon almost operated on the wrong eye of a patient after anaesthetising it on June 11, 2009. YIPES!
The next to last near miss in Rhode Island was when another surgeon at Hasbro Children’s Hospital on May 11, 2009 started to operate on the wrong side of a child’s mouth during a surgical procedure.
I hope that veterinary practice owners become aware, if they have not already done so, and implement not only standard surgical procedures, in checklist and not memory form, but other tools throughout their own hospitals, to ensure the safety of the pets entrusted to their care. It’s not just a practice owner’s duty, but if staff sees a need, then they should develop a checklist and ask questions later.
I just watched a show on television called “Whale Wars”, in which a group of committed, but slightly off-kilter, volunteers try to deter the Japanese whaling fleet from catching whales in Antarctica by either almost ramming their ship into the whaling ships, sending out Zodiak boats to harass the whalers, or throwing stink bombs onto the whaling ships. The Antarctic oceans are not a forgiving place, and if you have seen the “Deadliest Catch” on the Discovery Channel, you know that falling overboard in the Bering Sea is almost sure disaster.
In this episode, when the whalers were in sight, one of the Zodiak boats was unable to be launched because the on-board radar was inoperable. The opportunity was lost because the willy-nilly method by which the volunteers operated precluded accountability and responsibility. One of the quartermasters on the boat seized the initiative and developed a step-by-step-checklist for launching a Zodiak boat. Simple but effective.
Except for the part that the first mate of the boat, Peter, had no use for checklists because he didn’t need them he said. Well, actually he did need them, because anybody who had a hard time telling starboard from port on a boat should take all the checklists they can get.
In this case, what would the checklist accomplish? The Zodiak wouldn’t run out of fuel 5 miles away from the ship surrounded by icebergs and fog, crew safety would be maintained, and they could find their way back to the boat.
What would be the benefits to your own veterinary practice?