Today's Veterinary Practice

MAR-APR 2018

Today's Veterinary Practice provides comprehensive information to keep every small animal practitioner up to date on companion animal medicine and surgery as well as practice building and management.

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23 MARCH/APRIL 2018 ● TVPJOURNAL.COM ESSENTIALS Instructions: Think of a patient safety event that was reported in your hospital. Consider the common root cause of errors in healthcare and determine what some of the root causes for the problem were in your patient safety event. Label the different parts of the Swiss cheese diagram with the protective systems that are in place, along with some of the system flaws and/or human errors that may have led to the event. Take five minutes to fill out your worksheet independently, and then share with your table. Choose one story to share with the larger group. Brief Patient Safety Event Description: Story of Transformation: Have you changed anything: in your hospital as a result of this patient safety event? If so, please explain. If not, how could you change this from a Story of One to a Story of Transformation? Likely Root Cause(s) Leading to Patient Safety Event: 1. 2. 3. Swiss Cheese Diagram: Swiss Cheese Patient Safety Event Exercise CLINICAL RESOURCE PROTECTIVE SYSTEMS (Each slice of cheese — designed to prevent errors) HUMAN ERROR (Hole in the last slice of cheese) SYSTEM FLAWS (Holes in the cheese) HAZARDS PATIENT SAFETY EVENT © 2018 Today's Veterinary Practice. Today's Veterinary Practice grants permission to individual veterinary clinics to copy and distribute this handout for the purposes of client education. For a downloadable PDF, please visit todaysveterinarypractice.com .

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