We are human and we all make mistakes from time to time. The causes of these mistakes can be split into individual (active) factors and system factors[1]. Active causes of error include things like the impact of our personal situations on our judgement and the way that human brains work under pressure, using intuition, spotting patterns and make snap judgements (also known as system 1 thinking[2]). There is usually a human at the ‘sharp end’ of a veterinary error. But veterinary clinics are complex environments (systems), and these systems have a big role to play when it comes to errors. System failures can be organizational or a failure of leadership, they can be due to things like equipment design or drug labelling. A lot of the time, errors are actually due to multiple causes, but one of the biggest causes of error is down to a communication failure.
[1] Oxtoby, C., Ferguson, E., White, K., & Mossop, L.. We need to talk about error: causes and types of error in veterinary practice. Vet Rec. 2015;177(17):438-438.
[2] Kahneman, D. (2011). Thinking, fast and slow. macmillan.
