What Can a Near-Miss Tell Us About a Veterinary Workflow?

September 5, 2026
Clinical Practice & Technology

A clinician opens a patient record at the end of a demanding shift and notices that a laboratory result is already available but has not yet been marked as reviewed. A hospitalized patient is handed over to the next team, but an important detail remains only in a verbal conversation. Or an old dose remains in discharge instructions after the treatment plan has changed.

Not every event like this causes harm.

In patient-safety literature, a near-miss can describe an error that does not reach the patient but could have caused harm if it had.

Veterinary medicine has begun studying these events systematically. Wallis and colleagues reviewed 560 patient-safety incident reports from three veterinary hospitals. Drug errors were reported most frequently, followed by failures of communication, and the reporting system distinguished near-misses from events that reached patients with or without harm.

For a veterinary team, an event like this can be an opportunity to examine more than the action of one individual. It can prompt a different question:

What made an important piece of information easy to miss?

Safety should not depend on memory alone

Veterinary work involves constant movement between patients and tasks: consultations, emergency admissions, owner calls, laboratory results, discharges, procedures, and inpatient handovers.

Research into error in veterinary practice suggests that patient-safety events may involve not only individual decisions but also communication, workflow, and other system-level factors.

Patient-safety approaches therefore use process-level tools alongside professional vigilance: structured checkpoints, standardized communication methods, and review of reported incidents.

These tools are not intended to replace clinical reasoning with procedure. Their purpose is narrower: to make selected repeatable actions and points of verification more explicit.

Instead of asking only, “Who missed this?”, teams can also ask:

What in the workflow made this event possible?

Three places where structure may help

1. Repeatable checkpoints

A checklist is most useful when it supports a specific recurring process and makes a small number of important checks explicit.

Veterinary checklists have been studied particularly in perioperative care. Menoud and colleagues developed and implemented a perianesthetic safety checklist in a university small-animal teaching hospital. Staff reported perceived benefits for communication, and some respondents described situations in which the checklist helped identify an omitted action. The authors also documented implementation challenges, including concerns about time and resistance among some users.

A separate study at an academic veterinary institution compared surgical cases before and after implementation of a surgical safety checklist and reported a lower recorded frequency of perioperative and postoperative complications after implementation.

That finding should not be interpreted as evidence that any checklist will automatically improve outcomes in every practice. It reflects one intervention in one clinical environment.

The checklist itself does not make clinical decisions and does not guarantee safety. Its design has to fit the workflow in which it is used. For example, a discharge process might include explicit checks such as:

whether the final documentation reflects the current plan;
whether doses and instructions agree across records;
whether the follow-up plan is clear;
whether any results or other tasks remain outstanding and who is responsible for reviewing them.

The exact prompts will differ between practices. The purpose is not to create more paperwork, but to make a few deliberately chosen checks visible at the point where they matter.

2. Handoffs between clinicians or shifts

Communication failures were the second most frequently reported error category in the veterinary hospitals studied by Wallis and colleagues. That category included confusion over orders and failures to share information.

A handoff therefore needs to make the current working context of the patient usable to the next person.

A team might choose a short structure that answers questions such as:

Who is the patient, and why are they being monitored?
What has changed during this shift?
Which questions or uncertainties remain?
Which results or actions are still pending?
Who owns the next step?

This does not need to become a universal veterinary handoff template. Emergency hospitals, inpatient services, specialty centers, and small general practices will organize information differently.

The useful principle is simpler: the receiving clinician should be able to identify what is known, what is unfinished, and where attention is still required without reconstructing the entire case from scattered notes.

3. Fragmented case context

Clinical information rarely lives in a single place. Previous records, laboratory results, imaging, medication history, owner communication, and current notes may exist across different files and systems.

When a clinician needs to reconstruct a patient’s history, a concise working view of the current context may be useful.

It might include:

the primary problem;
relevant history;
current findings;
investigations and dates;
the current plan;
unresolved questions;
pending results or the next review point.

This should not replace the full medical record. It is a working representation of the information most relevant to the current stage of the case.

What near-misses can tell a team

One useful feature of incident reporting is that teams do not have to examine only events that already caused harm.

In the Wallis study, reported events were classified as near-misses, events that reached patients without harm, adverse incidents, or unsafe conditions. More recent veterinary patient-safety research has continued to examine reported events across veterinary care settings to identify recurring categories and circumstances.

A near-miss does not automatically reveal the cause of a future error.

It does, however, give a team something concrete to examine:

What happened?
At what point was it noticed?
Which information or responsibility was unclear?
Is there a small workflow change worth testing?

This approach does not remove individual professional responsibility. It adds examination of the system in which that professional is working.

Introducing safety habits without creating paperwork for its own sake

There is little value in standardizing an entire clinic simply because standardization sounds safer.

A more practical approach is to choose one recurring process—such as inpatient handoff or discharge—and look at where information repeatedly needs to be clarified or retrieved.

A short structure can then be piloted and reviewed:

Does it make relevant information easier to identify?
Which prompts are actually used?
Which create unnecessary work?
What is still missing?

The goal is not to design a perfect form. It is to create a process that remains usable under real clinical conditions.

What these tools cannot do

A checklist does not generate a differential diagnosis. A structured handoff does not replace reassessment of the patient. A well-organized record does not guarantee that a clinically important finding will be interpreted correctly.

Any structured process can also become a box-ticking exercise if its purpose is lost.

Standardization is therefore most useful for repeatable elements of workflow. Assessment of the individual patient remains a professional veterinary task.

Where Terav fits

Terav is being built as a case workspace for veterinary professionals. It brings together case-based clinical dialogue, laboratory results, and clinical documents such as PDFs and images within the context of an individual patient.

Its role is to make disconnected case materials easier to review, compare, and discuss.

Terav does not guarantee prevention of medical errors, and it does not make a clinic’s workflow safe by itself. It also does not make the final diagnosis.

Verification of clinically important information, assessment of the patient, and clinical decisions remain with the veterinarian.

That is the useful boundary of the technology: AI can help make context more accessible; the veterinary professional determines what that context means for the patient.

A near-miss does not necessarily mean that someone worked carelessly. It may point to a part of the workflow that deserves a closer look.

Sometimes “What made this easy to miss?” is a more useful question than another reminder to “be more careful.”