Update Your Equine Clinic to Reduce Medical Errors 

Caring for equine patients has risks, and every clinician wants to reduce these risks. Poor outcomes can result from medical errors, such as the wrong dosage, wrong treatment, wrong patient (yes it happens), and those related at least in part to the environment, such as injury to the patient and hospital-acquired infections. 

In compiling and discussing facility-related changes that make a positive difference for patient safety and medical outcomes, we begin with basic assumptions. We assume: 

• The hospital meets basic safety standards. Unloading areas are safe, the stalls are safe, and infrastructure (such as wiring) meets code. 

• The hospital has good biological risk management protocols. 

• The hospital already has standardized patient management, treatment protocols, and forms for communications.  

Beyond these basics are abundant opportunities for reducing errors and improving patient safety in your equine clinic. These are used in many industries, and many require only minor changes to the building, workflow, or equipment to implement. 

Foster a Culture of Error Reporting 

Error reporting is essential to understanding how errors occur and to implement changes. Many professionals are reluctant to report errors for fear of being disciplined and because of embarrassment. Overcoming this challenge is important.  

In your equine clinic, foster a culture of error reporting. Institute a supportive environment, and assure the medical team that they will not face disciplinary action from error reporting (unless the error was due to intentional negligent conduct).  

Error reporting has been instituted in other professions: 

• In human medicine. In a study at a 177-bed hospital in Canada, error reporting reduced errors from 9.5% to 2.0% over the study period. It should be noted that many errors are harmless, but not all.ⁱ 

• In the aviation industry. Required error reporting has reduced errors by half in the U.S. (as studied between 1983 and 2006).ⁱⁱ 

Perform a regular error review, including reporting immediately when they occur and systematic reviews of similar errors (so it feels less personal) during grand rounds. Improve daily communication by developing methods within veterinary work teams, similar to those used in aviation. For example, require verbal repetition by the person receiving instructions, particularly in urgent or emergent care situations. Provide regular training for employees of all levels, and create opportunities for continuing education, particularly in areas of weakness identified by regular error review.  

Facility Updates for Improving Hospital Communication 

• Meeting space. If error reporting is part of the equine clinic culture, then you will need space for meetings and good communication. If your meeting spaces are lacking or cramped, invest in better space. If there is no money for a hospital remodel, an adequate inexpensive solution is to purchase a modular building to serve as a meeting and overflow office space.  

• Technology improvements. Improve technology throughout the hospital. Put in more screens and workstations for viewing and charting to improve on-the-spot communication. 

Declutter the Equine Medical Spaces 

I have written in other articles about the importance of decluttering as it relates to patient safety. Clutter can create tripping, entanglement, and injury hazards for people and horses alike. This topic is important in the context of medical errors. Humans have limited capacity for attention, and our brains regularly tune out visual information so we can focus on tasks. Cluttered environments inhibit this focus.ⁱⁱⁱ  

Facility Updates for Clean and Decluttered Medical Spaces 

• Remove items that do not belong in a certain space. This is critical—medical areas are not storage rooms. If the item is not needed at all, then it should be disposed of. If it is needed but not in the space, it can be stored somewhere else. 

• Purchase and install storage cabinets for items. 

• For large items, consider building a closet with a sliding door to store them out of the way. This will improve the cleanability of the space and will reduce damage to expensive equipment. 

• Remove wall clutter, such as unnecessary signage (no one reads it), pharmaceutical giveaways, and posters. Paint the walls a neutral but light color other than white; white gets too dirty in medical spaces. Try a light gray, beige, or neutral color such as a gray blue or gray green. If desired, install tasteful branded art or a logo to your treatment room walls. 

• Install retracting power cords and hoses to prevent trip and entanglement hazards.  

Distraction-Free Medical Prep Areas 

Medication errors account for 55% to 69% of all errors in veterinary medical settings.^iv Dosage errors are most common, followed by the wrong medication and administration time. Because of the prevalence of medical errors related to medication, it is a priority to create a distraction-free zone for areas such as pharmacy where medications are stored, organized, and drawn for usage. Other tips include better labeling and color coding for weight-dosed drugs. 

Facility Updates for Pharmacy 

• Reduce chaos in the pharmacy by limiting truck restocking and other distracting activities. Carve out a quiet zone for medication preparation. 

• Separate lab areas from pharmacy areas. 

• Improve inventory control to include just-in-time ordering. Install shelving designed to be loaded from the back, so older medications are used first. 

Zoned Workflow in Your Equine Clinic

Humans will take the shortest route to go from one space to another. In equine clinics, this tendency can create problems. We regularly observe staff members cutting through medical space or surgery prep zones, especially in hospitals that have grown and expanded organically over time. If it is possible to reduce traffic through medical zones, the hospital will be safer. 

• Horses will startle less often. 

• Clinical teams will be less distracted. 

• Stress is reduced. 

• Cleanliness and biosafety are improved. 

Facility Updates for Workflow 

• Lay out your floor plan on a table, and mark the typical traffic flow with colored markers. Where do you see the collisions and crossed paths? Can you add any doors to reduce these problems? Are there any minor wall reconfigurations that can help? Do you need to install a covered walkway on the outside of the building so people can go around in bad weather? These minor changes might make huge improvements to your hospital’s function and safety.  

• Look at each room this same way. Does pack/prep have a clean/dirty flow? Do technicians have to walk far away to get supplies? See what you can do to reduce the complexities of performing daily tasks.  

Color Code Everything! 

While people do not read signage very well, simple visual cues such as color coding are highly effective for imparting important information quickly in your equine clinic. In human medicine, red indicates dirty and blue indicates clean. Quickly identifying clean versus dirty items can help improve care and reduce hospital-acquired infections. Color coding can also help improve efficiency and reinforce hospital protocols. 

Use color coding to provide cognitive cues for many places in your hospital, including but not limited to: 

• Clean and dirty instruments (see photo of Midmark cabinetry). 

• Tools to be used in isolation (red) versus healthy barns (blue). 

• Equipment for the field versus equipment that stays at the hospital. 

• Patient status (can use colored plaques on stalls). 

Facility Updates for Color Coding 

• Outline work zones (e.g., prep areas outside of isolation stalls) with colored tape on the floor.  

• Designate storage areas for items using color blocking. For example, a red border indicates storage of tools to be cleaned. 

• Purchase color plaques for coding patient status. 

• Purchase different colored tools for different spaces in the hospital. 

Organize and Standardize Your Equine Clinic

Variability in care leads to errors. The following strategies are employed throughout high-risk fields to increase standardization and reduce variability. 

• Checklists (such as preflight checks in aviation). These are also used in medical care. The problem with these is checklist fatigue. Employ them primarily to document the highest-risk procedures (such as general anesthesia for equine patients). 

• Equipment lists. For example, develop a standard equipment list for each ambulatory vehicle. The contents should be checked upon returning to the hospital from the field and prior to leaving in the morning. 

• Standardizing equipment in work zones. This can be anything from a large-scale strategy, such as standardizing room layouts, to a detailed strategy, such as placing the sink in the same space in every room. The less the team needs to reorient themselves from space to space, the more cognitive capacity they have for patient care. 

• Standardizing arrangements of drugs, syringes, and drug coding. This has been identified as an effective strategy in human medical spaces to reduce errors.^v 

• Standardizing equipment on trucks. 

Facility Updates for Standardizing 

• Purchase drawer inserts to help standardize equipment in drawers in each equine treatment or exam space. 

• If there is money to do so, reorganize the room infrastructure to standardize it from space to space in the hospital and provide the right point-of-use storage for each room. 

Equine Clinic Infrastructure Should Shine 

Poor infrastructure can create opportunities for errors and injury. These items might not feel like priorities, but they can have a profound impact on patient health and well-being. 

Facility Updates for Maintaining Infrastructure 

• Drains. Drains are notorious sources of contamination. Deep clean and flush the drains in the hospital regularly. This entails removing, scrubbing, and sanitizing the drain tops as well as the bodies. Ensure the drains are flowing well, and have them snaked if they are not. 

• HVAC. Obtain a maintenance contract for the hospital’s HVAC equipment to ensure it is serviced regularly, well-maintained, and has fresh and unclogged filters so the system can operate properly to support human and animal health and well-being. 

• Equipment. Some hospitals have older equipment. This is usually not harmful unless the equipment is used for sterilization. Autoclaves must be recertified every few years and replaced when they no longer work. Contact your autoclave manufacturer to determine the required maintenance for your critical sterilizing equipment. 

Summary 

Many small changes to your equine clinic can make significant differences for your practice’s success. Fewer errors not only benefits each equine patient; it also improves employee morale and the reputation of your business.  

Related Reading

• Design Considerations for Equine Veterinary Practices
• The Right Light for Your Equine Hospital
• Color Theory in Equine Veterinary Clinics

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