College Connection | Winter 2023
Panel provides guidance on managing adverse outcomes
College Connection | Winter 2023
LEARNING IN PRACTICE
Panel provides guidance on managing adverse outcomes
Case Summary
A veterinarian performed a laparoscopic spay on a dog which developed a burn three days later . The clients discussed the lesion with the veterinary technician who suggested it may have been a thermal burn and explained the use of heating blankets during the spay procedure . At the next appointment , the veterinarian suggested the lesion could be from rubbing caused by the surgical t-shirt .
The dog was taken to her regular veterinary facility where it was noted she had an irregularly shaped lesion , approximately 7cm in diameter . Clavaseptin was prescribed . At a follow-up , the veterinarian discussed the possibility of a thermal burn or a chemical reaction . The clients called the clinic , concerned the lesion was sustained during the spay . The clinic denied this possibility .
Case Outcomes
The Complaints Committee panel decided the allegations did not warrant a referral to the Discipline Committee . The panel advised the member to more readily acknowledge adverse outcomes and strive to be more forthcoming and sympathetic with clients . Professionally addressing mistakes , accidents or adverse outcomes is an important skill . Further , the panel recommended the member complete the learning module , “ Breaking the Silence : Discussing Medical Errors with Clients ”.
Case Considerations
In considering the complaint , the Complaints Committee panel reviewed medical records and written submissions . As is standard for all investigations , the panel considered previous proceedings , if any .
In the panel ’ s view , the lesion appeared to be consistent with a coagulation necrosis lesion . There are multiple possible origins , but a thermal burn is likely . A thermal burn can occur without negligence . Several pieces of equipment can cause a burn , even if the equipment is well-maintained . This is a known risk of heating units .
It does not appear that there was an error on the member ’ s part that led to this outcome . Accordingly , it is not the cause of potential burn that most concerns the panel , but rather , the member ’ s failure to appropriately consider and manage this adverse outcome and acknowledge that it may have occurred under their care .
Heating units can cause burns to a patient , even without malfunctioning . Changes in blood pressure or body temperature , moisture on the patient ’ s skin and drug responses , can all affect the heat transfer from the blanket to the patient . The dog was sparsecoated , increasing the likelihood of a burn .
The timing of the lesion suggested the injury may have occurred during the spay : thermal burns do not result in an immediate visible lesion . In this case , the t-shirt would have hidden the developing lesion . The subsequent necrosis of the skin layers occurs over several days . The lesion appears at its worst as the dead tissue begins to slough away which is often more than a week after the injury first occurs .
Although the member may not have acted improperly , their response appeared to lack professionalism . The panel expected the member to recognize the possibility the injury was a thermal burn suffered during the spay . The panel was concerned the member appeared unwilling to explore and supplement their knowledge of thermal burns and to sympathize with the clients ’ concerns . In the panel ’ s opinion , the member would benefit from guidance on how to respond to adverse outcomes in veterinary practice .
In conclusion , the panel acknowledged the clients ’ concerns and noted that by bringing forward a complaint , they have provided the College with an opportunity to assist the member to improve their practice .
Veterinarians have a responsibility to provide safe , quality care . The College assists veterinarians in doing so when matters are reviewed by the Complaints Committee . The public has a right to ask questions about the care that was provided to their animal ( s ) and this process provides veterinarians with feedback on whether they have met the standards of practice or whether there are improvements needed to mitigate risks in practice . The Committee provides advice or may request a veterinarian enter into an undertaking when remediation would reduce risks and support a veterinarian in meeting the standard of practice . Only the most serious cases , where there is bad intent , incompetence , reckless behaviour , or a history of failure to remediate at-risk behaviour are referred to the Discipline Committee for a discipline hearing to determine if an act of professional misconduct or serious neglect may have occurred . This example is taken from a case that was reviewed by the Complaints Committee and is offered as a self-reflection tool to support veterinarians in understanding how to meet the standards of practice .
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