Medication errors in veterinary anesthesia: a literature review.

OBJECTIVE: To provide an overview of medication errors (MEs) in veterinary medicine, with a focus on the perianesthetic period; to compare MEs in veterinary medicine with human anesthesia practice, and to describe factors contributing to the risk of MEs and strategies for error reduction. DATABASES USED: PubMed and CAB abstracts; search terms: [("patient safety" or "medication error∗") AND veterin∗]. CONCLUSIONS: Human anesthesia is recognized as having a relatively high risk of MEs. In veterinary medicine, MEs were among the most commonly reported medical error. Predisposing factors for MEs in human and veterinary anesthesia include general (e.g. distraction, fatigue, workload, supervision) and specific factors (e.g. requirement for dose calculations when dosing for body mass, using several medications within a short time period and preparing syringes ahead of time). Data on MEs are most commonly collected in self-reporting systems, which very likely underestimate the true incidence, a problem acknowledged in human medicine. Case reports have described a variety of MEs in the perianesthetic period, including prescription, preparation and administration errors. Dogs and cats were the most frequently reported species, with MEs in cats more commonly associated with harmful outcomes compared with dogs. In addition to education and raising awareness, other strategies described for reducing the risk of MEs include behavioral, communication, identification, organizational, engineering and cognitive aids.

Filgrastim Use in the Treatment of Azathioprine-Induced Myelosuppression Toxicity After Prescription Error in the Feline.

Only one report on the successful use of filgrastim (granulocyte colony-stimulating factor) in cats for severe neutropenia following azathioprine toxicity exists. Here, we report on a case in which a cat was prescribed methimazole but the medication was filled incorrectly with azathioprine tablets and the prescription label indicated a methimazole dosing regimen that was administered for three days before recognition of the error. On presentation, the cat's physical examinations were consistent with previous examinations before ingestion of azathioprine. A complete blood cell count revealed neutropenia and leukopenia. The cat later developed hyporexia, dehydration, and vomiting. Treatment included antinausea and appetite stimulant medications, filgrastim, and antibiotics. Filgrastim given as subcutaneous injections over the course of treatment increased neutrophil cell counts after suppression. The cat made a full recovery after responding to the treatment protocol. Based on the perceived response to filgrastim in this single feline case report, its use can be considered for the treatment of azathioprine-induced neutropenia in cats.

Error reporting in a large animal veterinary teaching hospital identifies medication errors occur most often in the prescribing phase of therapy.

OBJECTIVE: To identify the rate at which medication errors occurred over a 2-year period in a large animal veterinary teaching hospital and describe the types of errors that occurred. SAMPLE: 226 medication errors over 6,155 large animal visits occurred during the study period. Multiple errors may have affected the same patient. METHODS: Medication error reports from March 1, 2021, to March 31, 2023, were reviewed retrospectively and classified by species, type of drug, and month and day of the week the error occurred. Errors were categorized according to multiple previously developed systems to allow for comparison to other studies. RESULTS: 226 medication errors occurred over 6,155 patient visits in a 2-year period: 57.5% (130/226) were identified by a dedicated large animal pharmacist, and 64.2% (145/226) of errors were identified and corrected before reaching the patient. Prescription/medication order errors (58.4% [132/226]) occurred significantly more often than errors in medication preparation (21.7% [49/226]; P < .001) and administration (19.6%; P < .001). Antibiotics (48.7% [110/226]) and NSAIDs (17.7% [40/226]) were the drug classes most involved in errors. CLINICAL RELEVANCE: Most medication errors in this study occurred in the ordering/prescribing phase. This is similar to reports in human medicine, where standardized medication error reporting strategies exist. Developing and applying similar strategies in veterinary medicine may improve patient safety and outcome.

Incidence and type of voluntary reported perianesthetic medication errors in community veterinary clinics in Calgary, Canada.

OBJECTIVE: To collect medication error (ME) data during the perianesthetic period from small animal clinics. SAMPLE: 6 small animal general practice veterinary clinics. METHODS: Small animal general practice veterinary clinics were recruited in this prospective observational study, with staff given a presentation on medical errors and instructed on how to submit medication error reports to an online reporting system. Errors were classified according to type and timing. RESULTS: A total of 2,728 general anesthesia or sedation procedures were performed, with 49 ME reports submitted. One duplicated report of the same error was excluded, resulting in a ME rate of 1.8%. Most reports (69% [33/48]) were near misses. The remaining 31% were MEs that reached the patient but did not cause harm. Wrong dose errors were the most common type (63% [30/48]), of which 80% (24/30) were calculation errors. Premedication/sedation and maintenance were the most reported stages, at 47% (20/43) and 23% (10/43), respectively. None of the MEs reported resulted in an adverse event, with an approximately 2:1 ratio of near-miss to no-harm MEs. The observed patterns of MEs reported, including type and timing, represent a target for further education. CLINICAL RELEVANCE: These results quantify the ME rate in general practice veterinary clinics, providing an initial benchmark for MEs during the perianesthetic period.

Compounding errors in 2 dogs receiving anticonvulsants.

Two cases that involve drug compounding errors are described. One dog exhibited increased seizure activity due to a compounded, flavored phenobarbital solution that deteriorated before the expiration date provided by the compounder. The other dog developed clinical signs of hyperkalemia and bromine toxicity following a 5-fold compounding error in the concentration of potassium bromide (KBr).

Veterinary healthcare needs to talk more about error: For the wellbeing of our patients and medical teams.

Over the past 2 decades, patient safety has become an established priority in human healthcare. There is a large body of research in human medicine on harm caused by healthcare, its impact, and interventions to prevent it. There are also numerous guidelines, policies, and regulations to improve safety. An important realization has been that the same errors that harm patients can also harm members of the healthcare team. Empathetic handling of safety incidents can have positive effects on both the wellbeing of providers and their care of patients. An essential element in patient safety is the creation of a "culture of safety" within the health care team. A strong culture of safety describes a work environment where risk is acknowledged, individuals can report errors without fear of punishment, and the organization has a commitment to collaboratively implementing system changes to prevent future errors. A key element of safety culture is ensuring that healthcare team members are supported and asked to help create solutions for safer care. The principles of safety science and practices to improve safety have not yet been widely adopted in veterinary medicine. We describe a case of a serious medication error and how it was handled to illustrate key components of a culture of safety and a system-based approach to improvement. This case is timely as a recent review of patient safety events in 3 veterinary hospitals found medication-related errors to be the most frequently reported events. Open conversations about safety events and errors that can harm not only our patients but also our healthcare teams will help veterinary professionals learn from their mistakes, support members of the team, and prevent future harm.

What is your diagnosis? Marked hyperchloremia in a dog.

A 5-year-old neutered male Cavalier King Charles Spaniel was evaluated for a 3-week history of progressive paresis. The dog had been receiving potassium citrate capsules to acidify urine for the past 2 years because of an earlier history of urolithiasis. Results of neurologic examination, spinal cord radiography, and magnetic resonance imaging of the skull and spinal cord revealed no lesions that could have accounted for the neurologic signs. The main abnormalities on a clinical chemistry profile were marked hyperchloremia (179 mmol/L, reference interval 108-122 mmol/L) and an anion gap of -50.4 mmol/L (reference interval 16.3-28.6 mmol/L). Because of the severe hyperchloremia, serum bromide concentration was measured (400 mg/dL; toxic concentration >150 mg/dL; some dogs may tolerate up to 300 mg/dL). Analysis of the potassium citrate capsules, which had been compounded at a local pharmacy, yielded a mean bromide concentration of 239 mg/capsule. Administration of the capsules was discontinued and there was rapid resolution of the dog's neurologic signs. This case of extreme bromide toxicity, which apparently resulted from inadvertent use of bromide instead of citrate at the pharmacy, illustrates the importance of knowing common interferents with analyte methodologies and of pursing logical additional diagnostic tests based on clinical and laboratory evidence, even when a patient's history appears to rule out a potential etiology.

Recovery from Cyclophosphamide Overdose in a Dog.

An adult female spayed dog was evaluated after inadvertently receiving a total dose of 1,750 mg oral cyclophosphamide, equivalent to 2,303 mg/m2, over 21 days (days -21 to 0). Nine days after the last dose of cyclophosphamide (day +9), the dog was evaluated at Perth Veterinary Specialists. Physical examination revealed mucosal pallor, a grade 2/6 systolic heart murmur, and severe hemorrhagic cystitis. Severe nonregenerative pancytopenia was detected on hematology. Broad spectrum antibiotics, two fresh whole blood transfusions, granulocyte colony stimulating factor, and tranexamic acid were administered. Five days after presentation (day +14), the peripheral neutrophil count had recovered, and by 12 days (day +21) the complete blood count was near normal. A second episode of thrombocytopenia (day +51) was managed with vincristine, prednisolone, and melatonin. The dog made a complete recovery with no long-term complications at the time of writing. To the author's knowledge, this is the highest inadvertently administered dose of cyclophosphamide to result in complete recovery.

Selenium toxicosis in a flock of Katahdin hair sheep.

Selenium supplementation by injection is a common practice. Acute toxicosis from dosaging errors may occur. In this report, 23 of 56 ewes and all 24 lambs injected with selenium died. Tissue, whole blood, and serum concentrations aided in the diagnosis. Caution should be taken when supplementing selenium by injection.

[Intoxication with propylene glycol in two horses]. / Een intoxicatie met propyleenglycol bij twee paarden.

Two horses were accidentally administered propylene glycol instead of mineral oil. After discovery of the mistake intensive medical therapy with intravenous fluids, etc. was started, and both animals recovered fully from their clinical symptoms. Veterinarians use propylene glycol as well as paraffin routinely for the treatment of their patients. Mistakes are likely to be made because both medicines and sometimes their packing have a similar appearance. Several incidents have been reported in other countries. A large amount of propylene glycol given to a horse, but also to other animals, can be dangerous and immediate adequate intervention is necessary. The major cause of the problems in case of a propylene glycol intoxication is the high concentration of D-lactate that arises. Clinically, this primarily results in a depression of the central nervous system and in metabolic acidosis. Furthermore colic, diarrhoea and respiratory problems may occur.

Cyclophosphamide intoxication because of pharmacy error in two dogs.

CASE DESCRIPTION: An 8-year-old spayed female Yorkshire Terrier and 5-year-old castrated male West Highland White Terrier were evaluated because of cyclophosphamide intoxication subsequent to pharmacy error. Both dogs received cumulative doses of approximately 1,080 mg of cyclophosphamide/m(2) after cyclophosphamide was erroneously dispensed instead of cyclosporine by different pharmacies. CLINICAL FINDINGS: Both dogs became lethargic, and 1 dog also had anorexia, vomiting, and diarrhea within 2 days after initiation of cyclophosphamide administration. The other dog developed anorexia on the seventh day after initiation of cyclophosphamide administration. The dogs were evaluated by their primary-care veterinarians 9 and 11 days after administration of the first dose of cyclophosphamide, and both had severe leukopenia and thrombocytopenia. TREATMENT AND OUTCOME: One dog was treated on an outpatient basis with broad-spectrum antimicrobials, granulocyte colony-stimulating factor, and an appetite stimulant. The other dog was more severely affected and was hospitalized for 7 days, during which it was treated with broad-spectrum antimicrobials, gastroprotectants, granulocyte colony-stimulating factor, and cryopreserved platelet and packed RBC transfusions. Both dogs fully recovered after treatment. CLINICAL RELEVANCE: This was the first report of survival for dogs with inadvertent prolonged cyclophosphamide intoxication subsequent to pharmacy error. Although the 2 dogs had similar clinical signs and clinicopathologic findings, the severity of disease and treatment required differed for each dog. Dogs can recover from prolonged cyclophosphamide intoxication provided appropriate supportive care is administered.

Tramadol toxicity in a cat: case report and literature review of serotonin syndrome.

OVERVIEW: Tramadol toxicity has not previously been reported in a cat. CASE SUMMARY: This report describes the clinical signs, diagnosis and treatment of tramadol toxicity, manifesting as serotonin syndrome, in a cat in Australia. PRACTICAL RELEVANCE: For any cat with suspicion of serotonin syndrome, in particular secondary to tramadol overdose, it is recommended that decontamination, monitoring and supportive care are instituted as soon as clinical signs develop. Prolonged hospitalisation may be required in the event of a severe overdose. LITERATURE REVIEW: The literature relating to the pharmacology of tramadol and tramadol overdose, clinical manifestations of tramadol overdose, and serotonin syndrome in cats, humans and dogs is reviewed. Recommended treatment for tramadol overdose and serotonin syndrome is also discussed.

Permanent monoparesis in a dog after intramedullary injection of iohexol into the lumbar spinal cord.

UNLABELLED: Abstract CASE HISTORY: An 8-year-old, spayed, Doberman Pinscher bitch presented for assessment of acute hindlimb paresis. CLINICAL FINDINGS: During a lumbar myelographic contrast study a small volume of iohexol contrast agent was inadvertently injected into the cord parenchyma. After surgical hemilaminectomy for an intervertebral disc extrusion at L1-2 the dog recovered use of one hindlimb, but had ongoing extensor weakness of the left hindlimb. Left femoral nerve function had not returned after 14 months. DIAGNOSIS: EMG findings 14 months after the incident indicated persistent femoral neuropathy consistent with the intramedullary contrast injection at L3-4. CLINICAL RELEVANCE: Inadvertent deposition of iohexol into spinal cord parenchyma may be rare, but if it occurs it can have long-lasting consequences.

Status epilepticus attributed to inadvertent intrathecal injection of cefazolin during myelography.

OBJECTIVE: To describe a case of status epilepticus believed to be a consequence of inadvertent intrathecal administration of cefazolin in a dog undergoing a myelogram. CASE SUMMARY: A 4-year-old, 6.5 kg, male neutered Dachshund was referred for evaluation of an acute onset hind limb paraparesis. While performing a lumbar myelogram, cefazolin was inadvertently injected into the ventral subarachnoid space. Subsequent refractory seizure activity was attributed to the epileptogenic effects of intrathecally administered cefazolin. Supportive therapy led to eventual complete recovery. NEW OR UNIQUE INFORMATION PROVIDED: Although epileptogenic effects of intrathecally administered cefazolin are well documented in the human and experimental animal model literature, to the authors' knowledge this has not been characterized in the veterinary literature. This case highlights the need to be diligent and mindful when one administers medications, and describes the management of a dog adversely affected as a consequence of a medical error.