Lidando com erros de maneira eficaz

Introdução

É inevitável que ocorram erros em qualquer atividade humana, o que significa que os médicos veterinários estão sujeitos a cometê-los em sua prática clínica; de fato, os erros fazem parte integrante da medicina veterinária. Apesar de os erros serem esperados ao longo da carreira, o medo de cometê-los continua sendo uma das fontes mais comuns de estresse entre os profissionais 1. Esse medo pode ser agravado pelo estresse moral, que ocorre quando uma pessoa se encontra em situações que envolvem conflitos éticos 2; por exemplo, quando uma equipe clínica com poucos membros está lidando com um caso complexo ou quando um médico veterinário é solicitado a realizar um procedimento cirúrgico para o qual não se sente qualificado ou treinado. Nessas e em outras circunstâncias semelhantes que geram estresse moral, o risco percebido de erro aumenta, tornando o médico veterinário mais suscetível ao sofrimento psicológico.

Os receios em relação aos erros não se limitam apenas ao potencial dano ao animal, mas também abrangem preocupações sobre possíveis litígios, reclamações ao órgão regulador veterinário e as percepções de clientes e colegas. Em muitas situações, a primeira reação é ocultar o erro devido ao medo de ser responsabilizado ou por sentimentos pessoais de vergonha. Alguns médicos veterinários que cometem erros ou estão envolvidos em eventos adversos têm a capacidade de se recuperar rapidamente, utilizando habilidades e estratégias de enfrentamento que promovem a resiliência. No entanto, aqueles que persistem no erro em si ou se entregam à autocrítica induzida pela vergonha são mais propensos a sofrer um prolongado sofrimento emocional, e alguns podem até considerar abandonar completamente a profissão. É crucial tomar medidas significativas para aceitar que os erros são uma parte normal da prática veterinária, eliminar a cultura de "culpa e vergonha" que persiste na profissão, e abordar conscientemente os erros com transparência, perspectiva, apoio técnico e emocional, bem como oportunidades de aprendizado. Os erros são inevitáveis na prática veterinária e exigem uma abordagem consciente para serem superados de maneira rápida e eficaz.

Quão comuns são os erros médicos?

Cerca de 1,5 milhão de eventos adversos evitáveis ocorrem anualmente na área da medicina humana nos Estados Unidos, com quase 100.000 mortes atribuídas a erros médicos a cada ano 3. Embora a incidência de erros na medicina veterinária seja quantificada de forma menos robusta, é igualmente frequente. Recentemente, um estudo foi conduzido para avaliar o tipo e a gravidade dos erros médicos relatados em três estabelecimentos veterinários nos EUA (um hospital universitário de pequenos animais, um hospital universitário de grandes animais e uma clínica multiespecializada em pequenos animais), utilizando um sistema voluntário de notificação de incidentes. Os erros foram categorizados conforme descrito na Tabela 1, com exemplos. Os incidentes foram também classificados como quase acidentes (ou seja, o erro não afetou o paciente, mas poderia ter causado danos se tivesse), erros inofensivos (ou seja, o erro afetou o paciente, mas não causou danos), eventos adversos (ou seja, o erro afetou o paciente e causou dano), ou condições inseguras (ou seja, circunstâncias ou condições que aumentaram a probabilidade de um evento adverso para o paciente). Os registros foram revisados retrospectivamente para avaliar a gravidade do erro 4. Durante o período de estudo de três anos, foram relatados 560 incidentes, o equivalente a cerca de 5 erros por 1.000 consultas de pacientes. Este número é notavelmente mais alto do que o observado em consultas de cuidados primários humanos, onde aproximadamente 1 em cada 1.000 consultas resulta em danos evitáveis. Os erros de medicamentos foram os mais comuns identificados no estudo, seguidos por falhas de comunicação. Em 45% das vezes, os erros afetaram os pacientes sem causar danos, mas 15% de todos os incidentes resultaram em danos aos pacientes, incluindo 8% que resultaram em doença permanente ou morte. A maior proporção de erros ocorreu no hospital universitário de pequenos animais, embora isso possa ter sido simplesmente devido a relatórios mais diligentes 4.

Outro estudo analisou os tipos de erros registrados com base em quase 3.000 reclamações apresentadas à principal seguradora de responsabilidade civil veterinária do Reino Unido. Descobriu-se que os erros envolvendo cirurgia eram os mais comuns (41%), seguidos por tratamentos médicos (30%), partos (13%), diagnósticos (9%), aconselhamentos (5%) e anestesia (2%). Uma análise mais detalhada de um subconjunto dessas reclamações determinou que 51% dos erros ocorreram devido a limitações cognitivas, manifestadas na forma de distrações (ou seja, deslizes ou lapsos) e erros baseados em regras ou conhecimentos. Erros baseados em regras surgiram de uma aplicação incorreta do conhecimento, enquanto erros baseados em conhecimento resultaram de tentativas incorretas de resolver problemas complexos 5.

Tabela 1. Classificações, descrições e exemplos de erros médicos na medicina veterinária.

Putting mistakes in perspective

A 2001 survey of more than 100 new UK graduate veterinarians revealed that 78% had made a mistake since starting practice 6. However, it should be articulated that not all mistakes cause harm, just as not all adverse events result from mistakes. While some adverse events resulting from mistakes are due to negligence (i.e., failing to meet the standard of care), in some circumstances an individual will follow the correct procedure but make a mistake in the process. For example, a veterinarian may follow the standard of care by taking a radiograph to ensure that a nasal feeding tube is placed appropriately in the gastrointestinal tract – yet might review the radiograph and think that the tube is properly positioned when it is inadvertently placed in the airway; this would result in an adverse event if the dog is then administered food through the tube (Figure 1). Veterinarians will also sometimes hold themselves responsible for an unpredictable complication such as a drug reaction or the inherent biological variability of their patients, forgetting that animals treated in the same way for the same disease can have different outcomes. These scenarios are not the result of a mistake, but the clinician may take responsibility for their decision-making process that led to the adverse outcome. 

Consequences of near-misses and adverse events

Results from an online survey of more than 600 members of the Veterinary Information Network revealed that 74% of respondents reported involvement in at least one near-miss, and 30% reported involvement in at least one adverse event 7. The proportion of veterinarians experiencing both short- (≤ 1 week) and longer-term (> 1 week) negative impacts on their personal and professional lives were higher among respondents experiencing adverse events compared to near-misses (Table 2). This suggests that the negative consequences of making a mistake are worse when the patient is harmed compared to when the patient is not adversely affected, and also that the negative impact is felt more professionally compared to personally.

Table 2. Proportion of veterinarians adversely impacted in their personal and professional life after near-misses and adverse events.

Response to adverse events in practice

An online survey investigated the experiences and reactions of veterinarians working in “spay-neuter” clinics after serious adverse events that resulted in an unintended complication or death, and found that all respondents felt an immediate visceral reaction that included signs of anxiety or stress equivalent to the sympathetic nervous system fight-or-flight response. The feelings respondents described in conjunction with their physical experiences included anxiety, guilt, sadness, and self-doubt, as well as empathy for the clients or others impacted by the events (Figure 2). Some veterinarians processed and moved past these feelings within a day or a week, whereas others were deeply affected for months or even years afterwards. Over time, this resulted in one of two long-term outcomes: choosing to stay in their job or leaving their job (or the profession). What seemed to separate the veterinarians who were able to demonstrate resilience and move on faster after the adverse event from those who continued to experience it as recurrent trauma were the strategies they used for coping in the aftermath of what happened 8.

Negative and positive coping strategies

Unhealthy coping strategies after a mistake or adverse event can include substance use (i.e., drugs or alcohol), excessive sleep, avoidance behavior, over- or under-eating, and withdrawing from friends, family, or regular activities. In many situations there is an inclination to hide the mistake or not disclose the adverse event due to concerns regarding potential personal or professional ramifications. Because veterinarians often exhibit trait perfectionism, (i.e., an intolerance to mistakes or flawed behaviors), a mistake or adverse event is often accompanied by overly critical self-talk and profound concerns regarding other people’s views or opinions. A study investigating veterinary students found that self-oriented and socially prescribed perfectionism were associated with neuroticism, which had a negative correlation with resilience 9. Encouraging positive coping strategies and mitigating perfectionistic beliefs are important to quicken and enhance one’s ability to recover after mistakes.

There are many positive strategies that can help to mitigate the negative consequences of clinical mistakes and adverse events. These include disclosure; technical learning; perspective and appraisal; support and collegiality; and emotional learning in the form of mindfulness, healthy striving, and self-compassion.

Disclosure

Research demonstrates that patients prefer to know when a mistake was made, even if no harm was caused 10. A comprehensive review of the disclosure of patient safety incidents in human medicine demonstrates that healthcare professionals also support the admission of adverse events to patients and their families. The review affirmed that patients want frank and timely disclosure, an apology where appropriate, and assurances about their future care 11. The same needs likely exist for pet owners, meaning that it is important for veterinarians to maintain the belief that clients deserve to have all the information in the event of a patient-related error. An apology can be made to the owner, along with an explanation of what is being done to prevent the mistake from happening again (Figure 3). An offer to pay for any treatments needed following the error can also help to mitigate guilt among the veterinary team. Animals can then receive all additional treatment required consequent to the mistake, concerns regarding otherwise unexplained problems are decreased, and the veterinarian-client-patient relationship can be strengthened. The goal is that everyone has an opportunity to process and recover from the emotional stress of the situation, and less likely to engage in “blame and shame” behavior. 

Technical learning

Spay-neuter veterinarians involved in an adverse event were less likely to experience long-term personal or professional consequences and more likely to remain working if they tried to ascertain to learn why the mistake happened 8. Engaging in technical learning after a mistake can not only uncover why it happened, but also what can be done differently next time (Figure 4). An inability to understand what went wrong and how to prevent the same adverse event happening again are associated with increased anxiety for all members of the veterinarian team impacted by the mistake. Most importantly, the overall safety of the practice will be improved when errors are recognized, and steps can be taken to avoid the same mistake in the future. For example, if a mistake occurred because a protocol was unavailable or outdated, the protocol could then be written or updated with added safeguards to prevent the error from happening again.

Perspective and appraisal

After an error, it is important for the veterinarian involved to see the situation in its wider context – i.e., in terms of all the animals that have been helped and how few have been harmed. While mistakes happen, this does not mean those who make mistakes are “bad” veterinarians, and although it is natural to feel guilt, it is important to avoid that progressing to feelings of shame. Guilt stems from having done something wrong or failing to meet an expectation or obligation, whereas shame results from the concern about how a person appears to others. Shame is an intensely painful feeling or experience of believing a person is flawed and thus unworthy of belonging – so when a veterinarian makes a mistake, their shame is the feeling that others will believe they do not deserve to practice veterinary medicine. In other words, guilt is “I made a mistake,” whereas shame is “I am a bad veterinarian.” Guilt is a reasonable emotion and something most humans would feel after a mistake, but shame is unproductive, unhelpful, and leads to disconnection. It is important to resist feelings of shame and isolation and accept that everyone makes mistakes. It can also help to put limits on the magnitude of the situation; for example, recognizing that a patient did not die or that other patients were not impacted. Likewise, maintaining the belief that there is “more to life than veterinary medicine” can reinforce a healthy perspective.

Support and collegiality

Social support and a sense of belonging are important during stressful times. Specifically, if an individual believes that there is someone to lean on during times of duress, this offers protection against distress 12. So for errors in practice, knowing that someone else has “been there, done that” can bring incredible relief to someone who has made a particular mistake for the first time. Veterinarians who experience an adverse event are encouraged to lean on family, friends and colleagues for technical advice and psychosocial support (Figure 5). Sharing the experience with a trusted person or private social media group can be one way of garnering assistance and mitigating shame. It is also important to demonstrate support to other team members, as those who feel blamed rather than supported for reporting a mistake will be less likely to divulge the truth in the future and take longer to bounce back afterwards.

Emotional learning

How veterinarians handle and support themselves through an adverse event is paramount to their recovery 8. Rumination or dwelling on the situation will only lead to more distress, especially in combination with self-criticism. Self-doubt can be countered by having the humility to know that veterinarians risk doing harm while trying to do good. Likewise, distressful emotions are unavoidable after mistakes, and should be anticipated, and managing those emotions with mindfulness, healthy striving, and self-compassion are positive and helpful coping strategies.

Mindfulness

Mindfulness is a mental state achieved by focusing awareness on the present moment, while calmly noticing and accepting any feelings, thoughts, or bodily sensations without judgment. This helpful technique – increasingly researched during the last decade - can be used by individuals who find themselves ruminating on past mistakes or worrying about when the next mistake might happen. The benefits are numerous; a mindfulness practice can decrease anxiety and depression; help to manage substance use; improve physical conditions such as chronic pain, cancer, cardiovascular disease, and rheumatoid arthritis; enhance immune function; and manage hypertension 13. Most notably, it can reduce the detrimental effects of stress on the brain and body. Alterations in brain circuitry and complex brain function measured during neuroelectric and neuroimaging (e.g., functional MRI) studies are demonstrated in those who practice mindfulness, whereby cortical structures associated with attention, memory, executive functions and affective regulation are altered. This demonstrates that a mindfulness practice fosters attentional and emotional self-regulation, as well as behavioral flexibility. Changes in the limbic system, which controls emotions, behaviors, motivations and long-term memories, have also been noted in those who practice mindfulness 14.

Research investigating the benefits of mindfulness practices among human healthcare workers demonstrate many important benefits. Mindfulness training helps nurses cope more effectively with stress by improving their ability to remain focused and calm during stressful situations 15. In addition, nurses that complete mindfulness training have demonstrated improved clinical performance, an ability to cope with negative emotions, an awareness of thoughts and feelings during stressful events, and the ability to respond to the needs of patients 16. Medical students, physicians, and nurses also demonstrate improved self-awareness and self-care, as well as reduced risk of professional burnout when mindfulness training is completed 17. Additionally, a mindfulness practice has the potential to reduce adverse events among healthcare providers. A recent study in China compared a cohort of physicians who were randomized to either a meditation group or a control group. Mindfulness, patient safety culture, and patient safety competency were significantly higher among the physicians who had participated in the 8-week mindfulness meditation intervention compared to those in the control group, whereas adverse events were significantly lower 18. These findings suggest that not only can mindfulness mitigate stress, enhance self-care and positive coping strategies after a mistake, it also has the potential to lessen adverse events entirely.

Similar findings are arising in the veterinary literature, with suggestions that mindfulness practices can be beneficial – for example, a mindfulness training program reduced stress among faculty staff at a Caribbean veterinary school 19. Likewise, a study investigating salivary cortisol and α-amylase concentrations, as well as stress among fourth-year veterinary students performing a live animal surgery, found that those who performed a 5-minute mindfulness breathing exercise before the procedure had lower α-amylase and an improved sense of relaxation and calmness 20. As such, veterinarians are encouraged to regularly engage in formal mindfulness practices such as breathing exercises, body scans, yoga, or meditation (Box 1) to enhance their ability to stay present-minded and to improve mental health after mistakes or adverse events. Informal mindfulness practices can also be inserted throughout the workday, whether between appointments, during breaks, or while commuting. In these moments, especially when the mind is racing or ruminating, redirecting awareness to the present moment by focusing on breathing or noting the physical sensations in our body can be helpful. Practicing the 5-4-3-2-1 exercise (Box 2) is another way to lessen the stress response and become aware of the here and now.

Box 1. Examples of downloadable apps for starting a meditation practice.

Box 2. How to complete the 5-4-3-2-1 exercise as an informal mindfulness practice.

Healthy striving

It is an unrealistic expectation to think that, as humans, veterinarians will make it through their careers without making a mistake. It is not that veterinarians intend to harm an animal or that they are not being careful enough, it is because they are human and imperfect. So while many veterinarians expect themselves to be perfect, this belief inherently leads to psychological distress when mistakes are made. Healthy striving toward providing the best medical care based on the resources and time available is a much more productive and less destructive approach to clinical practice. A review of perfectionism among human healthcare providers during the COVID pandemic suggests that the stressful experiences of the global health crisis were exacerbated by the already high level of distress among perfectionists 21. The authors of this study advocate striving for excellence rather than striving for perfection, in terms of realizing when “good enough” is indeed “good enough” and learning not to internalize work-related dissatisfactions such that they then become generalized dissatisfactions with oneself. Accepting that at times “good enough practice” is better than “perfect practice” is paramount for veterinarians to maintain realistic expectations and avoid distress. 

Self-compassion

It is normal for distressful emotions to be felt after making a mistake, and it is important to manage them with forgiveness and self-compassion, i.e., compassion directed inwardly. Research investigating self-compassion and resilience among Australian veterinary students using an online survey found that students with higher self-compassion scores also had higher resilience scores 22. Similarly, acute care human nurses with higher self-compassion scores had lower scores for secondary traumatic stress, which is used as a measurement of compassion fatigue 23. These findings suggest that cultivating feelings of self-compassion can enhance a veterinarian’s ability to recover after a mistake or other similarly stressful event. This is reinforced by a recent report that found training can help healthcare providers cultivate self-compassion, leading to the promotion of self-care and reduced self-critical judgment 24. Self-compassion consists of three key states: self-kindness, mindfulness, and recognition of common humanity (Box 3), and it can be cultivated by using a variety of exercises such as self-compassion meditation, taking a self-compassion break, or performing self-compassion journaling (Table 3).

Box 3. Definition of the three components of self-compassion. *

(* From Self-Compassion by Dr. Kristin Neff: see https://self-compassion.org/)

Table 3. Steps for self-compassion journaling with examples.

Conclusion

Mistakes are common in veterinary practice and can impact veterinarians throughout their career. The ramifications of mistakes can be devastating, culminating in long-term personal and professional consequences or even a decision to leave the profession. Enhancing the resilience of an individual in the aftermath of a mistake is of paramount importance, and can be achieved with healthy coping strategies that include disclosing the error to the pet’s family, uncovering the technical aspects that will prevent the mistake happening in the future, broadening perspective as to the impact of the mistake, leaning on others for support, and emotional learning in terms of mindfulness, healthy striving, and self-compassion.