Originally published in the November 2015 issue of Veterinary Practice News. Enjoyed this article? Then subscribe today! 4 p.m. It’s time to catch up with medical records. This morning you removed a “routine” mass, likely a boring lipoma, from Kiki’s right chest wall. As you review your previous notes, you get a funny feeling in your six-pack area. There is a mention in your previous notes about a mass on the left chest wall. Strangely enough, the consent form says only “skin mass on chest wall.” No side is specified. Who’s to blame? The front desk? The head veterinary technician? The technician who admitted the patient? The assistant who clipped the wrong area? Your systolic blood pressure goes up a bit. 4:05 p.m. You rush to the kennel and double check. Sure enough, a similar mass is on the other (and correct) side of the chest and should have been removed. How could they have missed it? How could you have missed it? Your mouth becomes dry and your palms get sweaty, and you realize that you are the one ultimately responsible for what happened. How could you, an experienced and well-respected veterinary professional, make such a silly mistake? 4:10 p.m. It’s now too late to go back to surgery and make the incident go away. How are you going to explain it to the owners? What are they going to think? What is the staff going to think? What’s going to happen to your license? How about your reputation? 4:15 p.m. It’s time to call Ms. Smith and provide an explanation. How on earth are you going to do that? How do you explain the inexplicable? One way is to follow the advice of Dr. Christopher Adin, associate professor of surgery at North Carolina State University College of Veterinary Medicine. He suggests1 using the TEAM mnemonic to remember the four components of disclosing a medical error: truth, empathy, apologize and manage. Let’s review the steps. T is for "Truth" Before you unload the bad news on poor Ms. Smith, you need to prepare her psychologically. Begin with an introductory statement, such as “I have some bad news” or “I’m afraid I have bad news to share.” Because Ms. Smith will instantly assume that her beloved Kiki died during surgery, be ready to reassure her that this is not the case. If you fear that Ms. Smith may have a heart attack, you could say: “Kiki recovered nicely from anesthesia. However, I’m sorry I have bad news to share.” Then share it. Ask if the client would like more details. Be open to answering questions. If you don’t know answers, be honest. Say “I know this is difficult to hear; would you like me to explain what happened?” Or “I want you to know that I am willing to answer any questions that you may have.” E is for "Empathy" Empathy goes well beyond merely saying you’re sorry. It means putting yourself in Ms. Smith’s shoes and sincerely trying to understand how she might feel. After all, she trusted you to do the right thing with her beloved Kiki. Use words such as: “I can imagine how frustrating this must be,” or “I can see how disappointing this is to you.” A is for "Apologize" Your apology should be sincere. Don’t blame someone else. Own your mistake. Even though you didn’t admit the dog or clip the wrong side yourself, you are ultimately responsible for what happened. So you need to take responsibility for the error. Consider using words such as: “I am sorry to say that this error was due to a mistake that I made” or “I am so sorry. I wish that you and your dog did not have to bear the brunt of the damage resulting from my mistake.” M is for "Manage" Next, you need to fix the problem. Ensure that the patient’s and the client’s needs are met. What are the options to remove the correct mass? Who will cover the cost of removing the correct mass during a second surgery? Should you discount the fees for removing both masses? Should you offer to refer to a specialist? Will you cover that cost entirely? Beyond fixing the problem in the short term, clients often want to make sure the same error won’t happen to another patient. How will you ensure that this will never happen again? Here are several ways to identify the correct surgical site: Clearly identify the surgical site in your physical exam notes. The day of surgery, confirm the site with the client. Remember that clients regularly get their left side and their pet’s left side mixed up. Consider lightly clipping a small area near the mass. Don’t clip the area too close to the skin too long before surgery, as this increases the risk of postop infection. Place nail polish on one nail of the foot of the correct leg. Blue for males, pink for females. Make it fun! This can help defuse a tense situation. Confirm the correct site on the consent form and have the client initial that line. Have a receptionist specify the surgery site on the surgery board. Have a technician confirm the site by verifying the medical record, looking at the patient and double checking the consent form. All should be in agreement. Double check everything yourself one final time before making any skin incision. Keep in mind that we chose a simple, rather benign example, and a problem that is easy to fix. Errors can be far worse than removing a mass on the wrong side. The above reasoning also applies to killing a patient because of an overdose, because oxygen was never turned on, because the pop-off valve was closed or because of massive iatrogenic bleeding. So what happened to Kiki? The correct mass was removed on the following day at no charge. On the same day, Ms. Smith received a sophisticated flower arrangement with a note expressing hope that Kiki will feel well soon. A week later, the histopath report confirmed lipomas. Kiki made a complete recovery and Ms. Smith remained a faithful client of the practice. The sad fact is that oversights, adverse outcomes and errors are integral parts of being a veterinarian. How you manage them can have a profound effect on your success and happiness as a veterinarian. If you feel that you can manage your risk on your own, approaches like the TEAM concept may help you. If not, then there is a liability organization that can help you. Dr. Phil Zeltzman is a board-certified veterinary surgeon and author. His traveling practice takes him all over eastern Pennsylvania and western New Jersey. You can visit his website at www.DrPhilZeltzman.com, and follow him at www.facebook.com/DrZeltzman. Reference This information was adapted from a Bayer Healthcare Communication Project, “Breaking the Silence: Discussing medical errors with clients,” Institute for Healthcare Communications, 2007. It was presented by Dr. Adin at the American College of Veterinary Surgeons Surgery Summit in October 2014.
