Download and/or print the Adverse Event Log (MS Excel).
Direct questions and completed logs to adverseEventReporting@wellhaven.com.
Objective
Conduct a blind peer review process to learn from the rare but inevitable adverse events that occur in the practice of veterinary medicine. Determine what happened, why it happened and how to prevent in the future. The objective is not to determine blame, but to approach as compassionately as possible, recognizing the difficulty of these situations and the risk of triggering compassion fatigue or worse.
Adverse event learnings improve the quality of patient care and allow for healing of the team, families and patients involved. By determining contributing factors involved; team members, hospitals and our practice can apply findings to better ensure quality outcomes going forward. The goal is to avoid the fears that are often associated with peer review, and instead foster a culture of learning and positivity. Adverse events have been shown to result in providers loss of confidence, increase stress, sleep loss, emotional strain, damage to hospital culture and to contribute to burn out. The WellHaven Pet Health adverse event process provides a mechanism for teams involved to reflect, share, discuss, learn and recover emotionally. To provide a safe space for teams to discuss the impact of the event in order to decrease shame and encourage healing time together.
Analysis
Root cause determinations will inform adjustments to equipment, training, work flow, facilities, documentation, omissions, communication, protocols, procedures, fees, medications, dosages, etc. The majority of adverse events are due to a number of contributing factors, not a single human error.
Peer Review
Reviews are to be conducted initially by the principal doctor. Principal doctors are encouraged to complete the Adverse Event Form, make their own assessment, determine root causes, share with hospital team as appropriate and submit for review by the Medical Support Group for feedback. By the Principal doctor conducting the initial hospital adverse event discussion, the team is better able to advance patient safety, heal together and recognize the importance of the team in the delivery of quality care.
Principal doctors are encouraged to submit all unexpected patient deaths, significant adverse outcomes, state board complaints and any case which might benefit from peer review to the Medical Support Group. Any adverse event scoring a 4 or 5 on the AAHA adverse event severity scale is highly recommended to submit to the Medical Support Group for review. Please remember that all submissions will remain confidential. Adverse events are submitted via the modified AAHA adverse event log form.
The completed log is sent to adverseEventReporting@wellhaven.com. The Medical Support Group will discuss, assess and make recommendations. Findings will to be reported out to WellHaven medical practice teams periodically, but identifying information remains confidential.
The Medical Support Group, made up of a team of open-minded WellHaven family practice doctors and licensed veterinary technicians who seek to learn, not to blame. A diverse group of peers allows for better and broader perspective to best determine what learnings might be made. The process is blind (all identifying medical record indicators such as provider names, pet names, client names, addresses, hospital information, are redacted (blacked out) so that providers, teams and hospital locations remain anonymous.
Example Peer Review
- Upon adverse event, Principal doctor conducts review at the hospital using the modified AAHA adverse event report. For those Principals who may have not conducted a previous review, advice and coaching are available from Dr. Mary Luebbers, Dr. John Vickers, Dr. Troy Schlines, and Dr. Bob Lester Chief Medical Officer and past State Veterinary Medical Examining Board Chair.
- The Adverse Event Log is completed with findings from the principal and team, and then submitted to the Medical Support Group for blinded anonymous review via email to adverseEventReporting@wellhaven.com.
- Medical Support Group reviews events regularly - learnings may help influence practice wide equipment, training, process, medical record, formulary, communication, etc. or other areas, allowing for practice wide continuous improvement.
- Medical Support Group anonymous findings reported out via email to all Principal Doctors and Practice Managers following final review by submitting Principal Doctor when applicable. PDs and PMs then share findings with their teams as appropriate.
State Board Complaints
Should a case ever be submitted or threatened to be submitted to a state board, WellHaven Pet Health is ready and eager to assist. Our practice is equipped with expert in-house legal counsel, as well as past state board members ready and willing to assist our colleagues through the process. State board complaints should all be submitted asap by the modified Adverse Event Log for support and expert advice.