VetSafe incident-reporting system
VetSafe was developed by the Veterinary Defence Society( VDS) to enable veterinary professionals to document adverse events, near misses and other situations where patient care did not proceed as intended [ 16 ]. Information submitted to the system is analysed to highlight recurring themes, support reflective practice and identify areas where clinical processes can be strengthened.
VetSafe adopts a‘ systems thinking’ approach to patient safety by recognising that incidents often result from multiple contributing factors rather than individual error. Instead of assigning blame, VetSafe encourages veterinary teams to investigate the underlying reasons for an event, consider measures that could reduce the likelihood of recurrence, and introduce practical changes that will enhance patient safety and clinical practice in the future [ 16 ].
VetSafe is used to foster a no-blame culture and assist the team to make improvements by:
• Exploring WHY an event occurred
• Considering HOW this can be avoided in future
• Identifying WHAT improvements can be implemented.
VetSafe can provide a structured framework for documenting and analysing clinical events, supporting team reflection and identifying factors contributing to adverse events. Information gathered through VetSafe reports can inform quality improvement initiatives, including reviews of standard operating procedures( SOPs), development of targeted training, and discussion during team morbidity and mortality( M & M) meetings.
M & M meetings provide a dedicated forum for multidisciplinary teams to review clinical events in an open and non-blaming environment. These discussions allow team members to reflect on decision-making, communication, equipment and systems factors, while identifying opportunities to improve future clinical practice.
Discussion
Psychological safety is essential following critical events such as CPR, as it allows team members to openly discuss performance, errors and areas for improvement without fear of blame. A survey of 205 veterinary support staff found that although 69 % felt safe speaking up about errors, 31 % felt safe only sometimes, rarely or never, and 16 % reported previously withholding an error [ 17 ]. These findings highlight the importance of structured debriefing and a supportive team culture to encourage transparency, learning and improvements in patient safety [ 3, 17 ].
If a psychologically safe environment is created, the team members can share and feel supported through the process. It is also beneficial for the team to‘ touch base’ the following day or a few days later to ensure everyone is coping and approaching the review with a calm, clear mind after having some time to reflect on the event.
Structured review process
Following a CPR event, a structured review process can help the team explore multiple contributing factors that may have influenced the outcome, including:
• Clinical decision-making: evaluating whether CPR interventions were appropriate and aligned with current guidelines.
• Team communication and human factors: reflecting on whether roles were clearly allocated, communication was effective and team members felt confident in raising concerns during the emergency.
• Equipment and preparedness: reviewing whether emergency equipment, including crash cart supplies, drugs and monitoring devices, were readily available and functioning as expected.
• Training requirements: identifying whether additional CPR training, simulation exercises or protocol updates may improve future performance.
• Environmental and system influences: considering whether factors such as workflow, staffing, practice layout or resource availability affected the outcome.
Reviewing and discussing incidents in this way allows the veterinary team to recognise recurring themes, make changes, update protocols and, most importantly, create a psychologically safe culture where all members ' perspectives contribute to identifying safer ways of working together to achieve better outcomes. This includes all personnel, such as veterinary care assistants, veterinary nurses, veterinary surgeons and receptionists.
It has already been stated that time should be allocated appropriately following an event to discuss the process, existing strengths and any improvements. Structured debriefing provides an opportunity to recognise where previous training has positively influenced performance during clinical emergencies, while also identifying future learning needs. Evidence suggests that team debriefing can improve performance outcomes by approximately 20 – 25 % compared with having no debriefing [ 18 ].
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