How My Team Saved My Tail Yesterday

by Rebecca on February 16, 2014

bigstock-A-checklist-on-a-wood-and-meta-41809726Back about 6 years ago, I did not have a pre-anesthetic checklist in place.  Typing that sentence about makes me sick to my stomach because looking back that was so naïve, yet I had never really thought about it and it certainly was not commonplace.

Not having that checklist got me in a pretty bad situation when I was at a hospital operating on a dog who had bilateral CCL disease.  I had done an orthopedic exam on the dog a week earlier, so I made the mistake of not repeating the exam the day of surgery.  My assistants both had asked the technician helping us which leg we were operating on and were told the right leg.

Once we got into surgery, I was surprised because there was a partial CCL tear instead of what I had suspected was going to be complete CCL tear.  In the OR, I asked again about which leg we were supposed to be doing and was again told the right leg.  We proceeded on with the TPLO, which thankfully was uneventful.

All was good until the evening when the owner came in to visit the dog and she told the attending veterinarian we were supposed to do the LEFT leg.  The veterinarian called me and I almost became physically ill.  How could I have made such a stupid mistake?

It was really quite easy because the first time the pet came into the hospital the receptionist entered the right leg as being the worse leg NOT the left.  I am not remotely placing the blame on the hospital though because if we had a pre-anesthetic checklist in place this would not have happened.  I would have repeated my exam even though I had done one the week before because that is a box my assistants have to check off as completed EVERY time.

The good news is the dog recovered well from the first TPLO and went on the have the other leg fixed as well and is doing fine.

I tell you that story, not because I want to admit that I made such a huge mistake but instead to remind you of the importance of the checklist and a team that follows it.  Immediately, I created a pre-anesthetic checklist that MUST be completed on every patient.  How it works is once the patient is down, my assistants do the initial exam and then I double-check them EVERY time.

Yesterday, we arrived at a hospital to correct a medial patella luxation on a young crazy pit bull.  I actually snuck away to wolf down my lunch while Kadie and Nicole were getting the patient ready for surgery.  While I was eating, Nicole came to tell me that Kadie had actually palpated a CCL tear in the right leg even though we were there to do a patella surgery on the left leg.

I immediately got up to do my exam and sure enough that was exactly what was going on and thankfully my “on the ball” team and a pre-anesthetic checklist keep us from making a huge mistake for our patient!

Dr. Atul Gawande, a human surgeon, wrote “The Checklist Manifesto” about the importance of a checklist for keeping us focused on not forgetting the simple things-like doing an exam or giving pre-operative antibiotics.  Interestingly, he found that many doctors (and I would bet veterinarians too) resist checklists because they feel that medicine is as much an art as a science.  Though, doctors are not keen on being required to use a checklist, he found that 93% of them would want one used if they were having an operation.

I hope my bad experience can save you from making a similar mistake and I would challenge you to create a pre-anesthetic checklist if you do not already have one in place.

Do you have a story of a team member saving you from making a stupid mistake that you would like to share?

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{ 4 comments… read them below or add one }

Vet Changes World February 16, 2014 at 9:52 am

As a new graduate veterinarian I still had not gotten the instinctual feel for what drug doses were within the right range for pets of different sizes. My staff stopped me from giving a dose of pre-anesthetic that was too high. We started implementing checklists in our hospital as well as a result which has helped all of us keep our patients safer.

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Rebecca February 16, 2014 at 1:23 pm

Thank goodness for those great on the ball people who will speak up AND those checklists.

Thanks for sharing!

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Marie February 20, 2014 at 9:43 pm

Wow, I could not come up with a specific example but I know on a regular basis the staff will catch a mistake either made by me or by another staff member. I love lists so we have lots of lists of things that need to be done. We try to have a check and balance system in place and we have a anesthetic form which is kind of a check list but it is not used consistently by all members of the staff. We need to put into place an actual check list, from checking the anesthetic machine, to checking the patient, to monitoring the recovery of the patient. Marie

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rebecca February 23, 2014 at 9:02 am

Thanks for commenting!

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