Let's learn from mistakes!

[sofficat]

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Vets are people too and make a lot of mistakes. I think we should share them so we can learn from their mistakes and not repeat them!

Here a few from my experience...

-Vets tend to get lazy with physical exams: Missed broken wing on a bird, missed an obvious lymphadenopathy (enlarged lymph nodes) which changed everything with that case (presented for paresis- vet was thinking neuro- turned out to be neoplasia)
-Boarding a seizure dog overnight with no one there and when techs arrived that next morning the poor dog was seizuring (who knows how long) and had a temp of 108.
-Dog down in both legs, referred for neuro when it turned out to be bilateral CCL tears (a little bit more tricky, but a mistake non the less)

And here is why I am uncomfortable keeping animals overnight on IV fluids with no one in the hospital- dog got tangled up and choked himself (lived through it but was unconscious when techs arrived), cat ripped out catheter and bled A LOT, arm tangled up in fluids and swollen due to constriction.

 

[Bearby]

-Dog down in both legs, referred for neuro when it turned out to be bilateral CCL tears (a little bit more tricky, but a mistake non the less)

This one bothers me because cruciate tears are easy to diagnose. Even I can diagnose a cruciate tear and I haven't gone through veterinary school. I work with an orthopod once a month in a referral clinic and it's pretty straight forward. Drawer sign, joint tap...grr. I just feel bad for the owner who spent the money on a referral only to have to probably have another referral.

 

[sofficat]

This one bothers me because cruciate tears are easy to diagnose. Even I can diagnose a cruciate tear and I haven't gone through veterinary school. I work with an orthopod once a month in a referral clinic and it's pretty straight forward. Drawer sign, joint tap...grr. I just feel bad for the owner who spent the money on a referral only to have to probably have another referral.

Very true, and yes it was referred again. I have noticed that when vets think that the diagnosis is X they don't even look for anything else. Yes CCLs are pretty easy to diagnose but having a simultaneous bilateral presentation is odd. If it looks like a (neuro) duck quacks like a (neuro) duck... that's the mind set people get into so they just stop looking. Not a great way to practice medicine but unfortunately it happens more often than you think.
"You will miss more diagnoses for not looking than you will for not knowing" They engraved that in our brains for sure!

 

[DVMDream]

This one bothers me because cruciate tears are easy to diagnose. Even I can diagnose a cruciate tear and I haven't gone through veterinary school. I work with an orthopod once a month in a referral clinic and it's pretty straight forward. Drawer sign, joint tap...grr. I just feel bad for the owner who spent the money on a referral only to have to probably have another referral.

I can easily diagnose cruciate tears too; did so on Sunday. But if a dog came in not using either of its back legs my first thought would not be double cruciate tears. My first thoughts would be neurological or back injury. But that is where a good physical exam comes in....after a thorough neurological exam and no pain expressed (assuming there isn't also a back injury) when touching the spine then you would go to checking out each leg where you would (hopefully) find the drawer sign. But, you also have to remember it is sometimes very hard to have the leg show a drawer while the animal is awake because the dog is too tense. So sometimes you have to sedate the dog in order to acutally get a really decent drawer sign....and then what if the owner doesn't want to sedate... And the list continues. I could see how that one could easily get missed diagnosed, but it is about being as thorough as you possibly can.

 

[sofficat]

but it is about being as thorough as you possibly can.

👍👍

 

[lunajett]

This one bothers me because cruciate tears are easy to diagnose. Even I can diagnose a cruciate tear and I haven't gone through veterinary school. I work with an orthopod once a month in a referral clinic and it's pretty straight forward. Drawer sign, joint tap...grr. I just feel bad for the owner who spent the money on a referral only to have to probably have another referral.

Drawer sign on extension or flexion? Joints are complex; the drawer sign seems like a quick and easy diagnosis but there are some nuances. Jumping on the drawer sign can also lead to wasted money for the client.

 

[Bearby]

But, you also have to remember it is sometimes very hard to have the leg show a drawer while the animal is awake because the dog is too tense. So sometimes you have to sedate the dog in order to acutally get a really decent drawer sign....and then what if the owner doesn't want to sedate... And the list continues. I could see how that one could easily get missed diagnosed, but it is about being as thorough as you possibly can.

I agree that it wouldn't be the first thing I would think of, although it might be if it were a larger dog like a lab, not so much in a small dog. However, if the owner is willing to do a neuro consult, they should be willing to sedate their dog to get a better idea of what's going on. I can't say all of the doctors I work with are very thorough, but the majority of them are. My previous places of employment, the vets tended to do more of a focused exam based on what the owner perceived was the problem. I've learned a lot where I work now about the obvious not always being correct.

 

[DVMDream]

I agree that it wouldn't be the first thing I would think of, although it might be if it were a larger dog like a lab, not so much in a small dog. However, if the owner is willing to do a neuro consult, they should be willing to sedate their dog to get a better idea of what's going on. I can't say all of the doctors I work with are very thorough, but the majority of them are. My previous places of employment, the vets tended to do more of a focused exam based on what the owner perceived was the problem. I've learned a lot where I work now about the obvious not always being correct.

One would hope that they would be willing to sedate their dog if they are willing to do a neuro consult but I have seen stranger things. There are people completely against sedating their animals simply because they are too afraid and it does not matter what you tell them they will not change their minds.

I once had a client who was 110% against putting her dog on prednisone for severe allergies but was fine using Temaril-P because that is what her previous vet had given her. When I explained to her that Temaril-P has a steroid in it (prednisolone) she did not believe me. So I showed her the bottle and she said, "Oh that says prednisolone not prednisone." I tried to explain to her that they are very similar and have the same side effects but she did not believe me.

Clients can be very weird and very particular about what they will and will not allow a vet to do with their pet.

Not saying that happned in this case but it would not surprise me at all if someone did refuse to sedate their dog but was completely ok with being referred to a neurologist.

 

[sunshinevet]

I once saw an owner completely refuse to allow us to test for drawer sign in what was an obvious cruciate rupture. With or without sedation - she didnt want us hurting the poor thing. Not that she was going to approve surgery - obviously walking around with an unstable stifle is better!

I, however, think this thread would be a whole lot more constructive if it was used to discuss different methods of avoiding burnout, how we've seen it happen, how we've seen it avoided, how we're going to avoid it, how we're going to stay sharp etc.

To me, it just comes off as a bit trite that pre-vet and vet students are making lists of mistakes that other vets have made, for whatever reason. You actually have no idea whether or not you'll be better until you are out there doing it. You'd be far better off making a list of how to prevent yourself being lazy and cutting corners (because i guarrantee you, that once you get some experience you WILL) than merely listing things you've seen missed.

I hope that made some vague sense - my brain is currnetly being fried from third year exams...

 

[Bearby]

I once saw an owner completely refuse to allow us to test for drawer sign in what was an obvious cruciate rupture. With or without sedation - she didnt want us hurting the poor thing. Not that she was going to approve surgery - obviously walking around with an unstable stifle is better!

I, however, think this thread would be a whole lot more constructive if it was used to discuss different methods of avoiding burnout, how we've seen it happen, how we've seen it avoided, how we're going to avoid it, how we're going to stay sharp etc.

To me, it just comes off as a bit trite that pre-vet and vet students are making lists of mistakes that other vets have made, for whatever reason. You actually have no idea whether or not you'll be better until you are out there doing it. You'd be far better off making a list of how to prevent yourself being lazy and cutting corners (because i guarrantee you, that once you get some experience you WILL) than merely listing things you've seen missed.

I hope that made some vague sense - my brain is currnetly being fried from third year exams...

I think that's a good idea. I think that a lot of DVMs continue with the mindset that we all have as pre-vets and veterinary students where basically all we do is vet med. Granted, I think we all have some things that we do on the side - clubs, sports, going out with friends - but really this profession consumes us from the moment we decide to go into it. I think one of the most important things to keep us all sane and focused, is to take some time to relax. I've known vets who worked for 5 years without a vacation day. You're bound to be worn out and cutting corners by then. You have to be able to do stuff for yourself, too. For example, I like to go out and dance with my friends. It's great stress relief and it takes my mind off everything else for a little while. Hopefully I'm not embarassing myself by dancing in clubs when I'm like 40, but I want to be able to get myself out of my house. Another vet that I currently work for doesn't go anywhere unless someone picks her up and takes her. She's a lot of fun once you get her out, but I don't want that to be me.

 

[LivestockDoc]

Hopefully I'm not embarassing myself by dancing in clubs when I'm like 40, but I want to be able to get myself out of my house.

Oh crap! Is there a No Dancing rule after 40? I guess I missed my chance!
😀

 

[Bearby]

Oh crap! Is there a No Dancing rule after 40? I guess I missed my chance!
😀

oh, no no no...I will still be dancing, I just hopefully won't be embarassing myself

 

[WhtsThFrequency]

I've known vets who worked for 5 years without a vacation day. You're bound to be worn out and cutting corners by then. You have to be able to do stuff for yourself, too.

Having been through it (and still it in 😉 ) I cannot emphasize this enough. My first month of residency, I was in it to win it. I worked far too long and wore myself out. Being in a new place with no friends and no family means work becomes your life since you have nothing else to do. Finally realized I was tired and not looking at things properly when, during one of our many slide review sessions, I realized that out of our ~16 cases I had called two benign tumors malignant, one malignant tumor benign, and had totally missed others - pretty easy calls too, my other resident-mates got them fine. After that I scaled back down, and now its much better. Its not cutting corners per se (although some people do that) its just mental exhaustion. Especially in path, where the amount of information is literally overwhelming. Take time for yourselves, guys 🙂

 

[StartingoverVet]

To me, it just comes off as a bit trite that pre-vet and vet students are making lists of mistakes that other vets have made, for whatever reason. You actually have no idea whether or not you'll be better until you are out there doing it. You'd be far better off making a list of how to prevent yourself being lazy and cutting corners (because i guarrantee you, that once you get some experience you WILL) than merely listing things you've seen missed.

...

Completely disagree. Observing and learning from other's mistakes is a crucial part of the process of education. Would you prefer to remain ignorant and make the same mistakes?

Going up to an actual vet and telling them they were wrong would probably be impertinent and counterproductive, but observing how errors occur is not.

In every professional career I have seen, a major part of becoming adept is analyzing the mistakes of others. I have done it thousands of times in flying and in finance and elsewhere. In flying it could be your (or another's) life you save, in vet med, it could be the animal's life (in finance it was someone else's money - doesn't seem so bad).

Never be afraid to use a critical eye when observing the practices of other people. You might end up doing the same thing, but at least you have a fighting chance of avoiding a similar fate.

 

[sofficat]

Completely disagree. Observing and learning from other's mistakes is a crucial part of the process of education. Would you prefer to remain ignorant and make the same mistakes?

Going up to an actual vet and telling them they were wrong would probably be impertinent and counterproductive, but observing how errors occur is not.
.

Thank you.

I was working for a new grad and a dog seizured and she forgot to get a blood glucose and the dog already left. She felt so bad for making that mistake and told me "don't ever forget to get a blood glucose on a seizuring animal!" Ya know what? I think of that all the time.
How are we going to know what mistakes to avoid if we don't observe our peers in our profession?? We are not simply pointing out mistakes to make fun of others- as the title says "LET'S LEARN FROM MISTAKES"

 

[HopefulAg]

Ok so here's a more...'fun' one. Words of wisdom passed down from my vet.



He was making an observation that when people get busy/involved in a task, they tend to have their mouths hanging slightly open. Don't do that! All sorts of fluids can go flying at any moment without warning in a vet clinic. His particular case he relayed to me was when him and a friend of his were doing rounds, they were looking into a cage at a patient. Well the girl he was working with opened the cage, touched the animal and suddenly: explosive diarrhea. Explosive, projectile diarrhea. They both got more or less covered and guess who had their mouth open? The girl washed her mouth for about 15 minutes so goes the story, though I often wonder if the 'girl' was actually him 😀

 

[sumstorm]

Completely disagree. Observing and learning from other's mistakes is a crucial part of the process of education. Would you prefer to remain ignorant and make the same mistakes?

I think part of the problem here is that you, I, and most of the members on this forum CAN'T accuratly analyze the mistakes. Some may be mistakes, some may be client choices in care, and some may be miscommunications.

Unless we are seeing entire case files, including supporting documentation, how are we accuratly analyzing cases. I take everything I read online with a grain of salt (just like I ask clients to do.)

So when I read 'doctor didn't find broken wing' I want to know a lot more about that situation than assuming an exam was done too hastily; IE was the bird so stressed the exam needed to be continued later, but rehabber or owner refused? We do a lot of bird exams with long delays between so we don't kill the bird. Did the owner throw a fit about the bird being hurt? I see that alot. Did the owner not appreciate how much stress can damage a bird and get upset when there wasn't an instant fix? Did the vet decide that there might be a break, but that it wouldn't change the treatment plan? Unless I have the entire case history, at least for me, kibbitzing isn't useful. It's kind of like reading the path report and finding there was an unexpected tumor pressing on a major artery and saying 'ah hah, obviously we should have done X!' I, like most folks, prefer knowing what happened and why, but assuming it would have changed the treatment in the trenches isn't the same thing. If the OP wants to provide detailed case studies, I think that is an entirely different issue.

Also, sharing what vets have suggested to us, handed down as advice is very different as well.

Some of the things listed is why we do differentials and work through a process. I've seen folks think something was an 'obvious' lymphadenopathy and discover it is actually a tumor, or a swollen salivary gland. Seizure dog being boarded; do we know that wasn't the best option the clients could afford? Would it have been better to refuse it care? At this point, based on the information provided, the client could be the local AC. Do we know the cranial cruciate dog wasn't also showing other signs that may have suggested neuro issues? And possibly had owners so worked up that they were going to insist on a neuro consult, or owners that refuse sedation with a dog that is so aggressive or painful it won't allow a thorough exam?

I agree that learning from the mistakes of others is valuable but I am questioning whether we, with such little information and lack of training (at least I haven't obtained my DVM yet), can even accuratly evaulate whether a mistake was made by a vet, or if this was the best course of action given the situation and the constraints that we aren't aware of in these specific cases.

 

[sunshinevet]

Thanks sumstorm, for putting what I meant so accurately and eloquently! There is a big difference between a vet advising you to keep your mouth shut at all times (which is important, lol!) and actually posting about potential misdiagnoses. As vet students we have a slowly growing ability to understand the diagnostic process of each of these cases and therefore actually appreciate how these mistakes happen (because until you appreciate how they happen, you actually aren't learning anything constructive) and as pre-vet students, almost none. I don't think its helpful/constructive/actually conducive to learning to post "always check lymph nodes, because Dr X once didnt and this really strange case he had turned out to be cancer" because one day, you probably wont, because the dog has an anal gland abscess, you know? The most important way you can prevent those mistakes is by staying aware of those zebra cases amongst your horses - but that will come with time and vet school, and I don't think this thread will help, and I find it a bit inappropriate.

But I mean, if you want to make it general veterinary lessons learned, like, before approaching any animal find out why its there, otherwise you'll end up covered in what the dog given apomorphine was waiting for, thats completely different.

 

[sofficat]

I think part of the problem here is that you, I, and most of the members on this forum CAN'T accuratly analyze the mistakes. Some may be mistakes, some may be client choices in care, and some may be miscommunications.

Unless we are seeing entire case files, including supporting documentation, how are we accuratly analyzing cases. I take everything I read online with a grain of salt (just like I ask clients to do.)

So when I read 'doctor didn't find broken wing' I want to know a lot more about that situation than assuming an exam was done too hastily; IE was the bird so stressed the exam needed to be continued later, but rehabber or owner refused? We do a lot of bird exams with long delays between so we don't kill the bird. Did the owner throw a fit about the bird being hurt? I see that alot. Did the owner not appreciate how much stress can damage a bird and get upset when there wasn't an instant fix? Did the vet decide that there might be a break, but that it wouldn't change the treatment plan? Unless I have the entire case history, at least for me, kibbitzing isn't useful. It's kind of like reading the path report and finding there was an unexpected tumor pressing on a major artery and saying 'ah hah, obviously we should have done X!' I, like most folks, prefer knowing what happened and why, but assuming it would have changed the treatment in the trenches isn't the same thing. If the OP wants to provide detailed case studies, I think that is an entirely different issue.

Also, sharing what vets have suggested to us, handed down as advice is very different as well.

Some of the things listed is why we do differentials and work through a process. I've seen folks think something was an 'obvious' lymphadenopathy and discover it is actually a tumor, or a swollen salivary gland. Seizure dog being boarded; do we know that wasn't the best option the clients could afford? Would it have been better to refuse it care? At this point, based on the information provided, the client could be the local AC. Do we know the cranial cruciate dog wasn't also showing other signs that may have suggested neuro issues? And possibly had owners so worked up that they were going to insist on a neuro consult, or owners that refuse sedation with a dog that is so aggressive or painful it won't allow a thorough exam?

I agree that learning from the mistakes of others is valuable but I am questioning whether we, with such little information and lack of training (at least I haven't obtained my DVM yet), can even accuratly evaulate whether a mistake was made by a vet, or if this was the best course of action given the situation and the constraints that we aren't aware of in these specific cases.

Wow you really took a lot of time for that post! I do appreciate that, however I still think that observing other vets can make for very valuable information! How am I going to know what mistakes I could potentially make and what better way to prevent them then by observing others? I understand that in this profession we do not (should not) talk badly about other vets... and noticed I have not. Never once have I said this vet suck because they made this mistake. Absolutely not! We ALL make mistakes and I learn from my own... AND from others.

So- without getting into details since this is a public forum... all the cases I mentioned (with the exception of the bilat. CCL tears- I just heard about that from a classmate) I was personally involved in and knew the entire case and history (and on this forum I would hope people wouldn't include that). There was no critical bird who couldn't withstand a full exam or noncompliant client who wouldn't bring their dog to an overnight clinic or any "what ifs." And EVEN IF the mistakes mentioned where from the client declining things at least we can learn how important AMA forms are! 😉

 

[sofficat]

T I don't think its helpful/constructive/actually conducive to learning to post "always check lymph nodes, because Dr X once didnt and this really strange case he had turned out to be cancer" because one day, you probably wont, because the dog has an anal gland abscess, you know?

You always always always check lymph nodes on your physical exam- no matter what! And anal gland abscess isn't a great example because A) infection could have spread to nodes and B) your second differential for that is most likely anal gland neoplasia and you better check your nodes if you have any type of cancer.
Check lymph nodes always.... and my example is one (of many, I'm sure) examples why.

 

[Bill59]

I have noticed that when vets think that the diagnosis is X they don't even look for anything else.

That's called premature closure of diagnosis, and is the single most common cause of diagnostic error. If the clinician strongly considers a particular diagnosis before sufficient verification, the clinician is often resistant to considering an alternative diagnosis even if the face of mounting evidence that the initial diagnosis is wrong. In effect, you become "attached" to the diagnosis and resist any other diagnosis.

By the way, this cognitive bias is strongly correlated to lack of experience.

 

[sofficat]

That's called premature closure of diagnosis, and is the single most common cause of diagnostic error. If the clinician strongly considers a particular diagnosis before sufficient verification, the clinician is often resistant to considering an alternative diagnosis even if the face of mounting evidence that the initial diagnosis is wrong. In effect, you become "attached" to the diagnosis and resist any other diagnosis.

By the way, this cognitive bias is strongly correlated to lack of experience.

Cool definition, Webster! I didn't know that was a thing. What I find interesting though is that it is linked to lack of experience. I would think that the less experience you have the more you are open to a larger list of differentials and the more experience you have the more you would think "oh I've seen this many times before and it is always X therefore that is what it is." Then you would be resistant to another diagnosis because that would prove your experience knowledge wrong. hmmmm...

 

[BlacKAT33]

In ICVM we learned 2 things: HISTORY AND PHYSICAL EXAM

It sounds funny and we were just laughing each time our prof repeated it, about 100 times, but it is true in any profession...when you repeat the same things every day you get lazy and tend to take short cuts. He even posted stats about medical misdiagnoses' (is that grammar right?? lol) and how 80% of them all lead back to a mistake in the physical exam or history (don't quote me on that stat lol) i tried to find it in my notes but cant at this moment

 

[StealthDog]

I would think that the less experience you have the more you are open to a larger list of differentials and the more experience you have the more you would think "oh I've seen this many times before and it is always X therefore that is what it is." Then you would be resistant to another diagnosis because that would prove your experience knowledge wrong.

Speaking from my personal (short) experience as a new vet, I'd definitely agree with Bill59. It's so easy to see "puppy with no vaccines, vomiting, bloody diarrhea" on the schedule and immediately call it parvo before you've even done your physical exam, since I've seen about 10 cases with that presentation and all have been parvo. Someone with 20 years of experience has seen hundreds of cases with that presentation, and seen them turn out to be parvo, or whipworm, or GI foreign bodies, or intussusceptions, or dietary indiscretion, or...

I try to always go into an exam room with an open mind and come out with a problem list rather than a "diagnosis"... then let my problem list lead me to differentials and potential diagnostics needed to reach a diagnosis.

 

[Bill59]

What I find interesting though is that it is linked to lack of experience. I would think that the less experience you have the more you are open to a larger list of differentials and the more experience you have the more you would think "oh I've seen this many times before and it is always X therefore that is what it is." Then you would be resistant to another diagnosis because that would prove your experience knowledge wrong. hmmmm...

Clinical reasoning is like any other skill, it improves with experience. That's not to say that it can't be taught or learned, for example in a classroom setting. But it tends to improve the more you do it -- like almost everything else.

 

[StartingoverVet]

In ICVM we learned 2 things: HISTORY AND PHYSICAL EXAM

It sounds funny and we were just laughing each time our prof repeated it, about 100 times, but it is true in any profession...when you repeat the same things every day you get lazy and tend to take short cuts. He even posted stats about medical misdiagnoses' (is that grammar right?? lol) and how 80% of them all lead back to a mistake in the physical exam or history (don't quote me on that stat lol) i tried to find it in my notes but cant at this moment

Another interesting fact from that class (see I actually paid attention, not always reading SDN and facebook):

In one case study, 37% of the diagnosis differed between the clinical diagnosis and the pathological post-mortem diagnosis.

Just some food for thought.

 

[alliecat44]

I have to say I agree with sumstorm, sunshinevet, Bill59 and StealthDog. We don't know the circumstances surrounding these misdiagnoses and it's really really difficult to judge. For instance, do you even know what a physical exam criteria would be for diagnosing a broken wing in a bird? Unless it was a bone that was needed for structural support and/or inhibited the neurological function of the appendage and/or there was obvious crepitus/displacement, I don't think I would be able to diagnose one on PE alone. (There are a lot of bones in a bird wing!) I don't think pre-vets (or even most vet students) really have a handle on judging veterinarians' mistakes unless in cases of gross negligence/ (Such as a vet who gave Depo-Medrol IV at the Solu-Medrol protocol dose for intervertebral disc disease.)

Speaking for myself, I worked for years in specialty practice--4 years in ER/CC, 3 years in surgery, 3 years in neuro--all with boarded specialists. At the time, I was exposed to and involved in more complicated cases of X Y Z than many referring veterinarians had seen in their career. Certain things were "missed" by vets that I felt were totally "obvious"--because I dealt with similar types of cases all the time, whereas the rDVMs dealt with each of those cases maybe once a year or even once in their career.

Now that I'm almost through veterinary school and realize the depth and breadth of my lack of knowledge, I find myself much less confident about pinpointing a diagnosis than I did fairly breezily when I was just a tech and #1. My opinion wasn't going to make or break the animal's care and #2. It wasn't my responsibility and most importantly #3. I really didn't know a whole hell of a lot relatively speaking. It's cliche but it's true--the more you know, the more you realize you don't know. I'm much much less apt to "fault" a vet now that I know what it's like from the other side of the fence and how confusing/inconsistent things can appear--and how many zillions of differentials go through your head and are worked through verbally with your clinician.

I think the most useful point in this thread is as BlackKat said--history and physical exam are of the utmost important. And SOV pointed out that the path dx was different from the clinical dx 37% of the time--which means that your clinical diagnosis gives you the right answer 63% of the time. Which is pretty damn good.

 

[twelvetigers]

And SOV pointed out that the path dx was different from the clinical dx 37% of the time--which means that your clinical diagnosis gives you the right answer 63% of the time. Which is pretty damn good.

...which is why I want to go into path. 😀

 

[HopefulAg]

Crap...gonna be submitting samples to TT and she'll reply with "are you SURE you graduated from vet school? It was SOOO obviously this...glad I could do your job for you!"

 

[twelvetigers]

Aww, no! I'd be nice! I'm always nice!