More information about Medical Errors in Veterinary Hospitals

Medical Errors in Veterinary Hospitals

Last year, I was involved in a medical error involving a vaccine.  While moving quickly, my assistant inadvertently administered an oral Bordatella vaccine subcutaneously.  When I did a search on VIN, this was something that had been discussed in 36 separate posts.  When I called ASPCA poison control, they had received 18 calls just in the previous year about this type of error.  We informed the owner right away, followed all recommendations, and luckily the dog had no adverse effects.

I wrote a blog about how system changes, not just being more careful, are needed to prevent mistakes.  I discussed that a change in the design of the oral vaccine vials , as used in human oral vaccines, could prevent this type of error.

As I have previously discussed, there are very few publications on medical errors in veterinary medicine.  A 2018 survey study in JAVMA reported that 73% of the 606 reporting veterinarians had been involved in at least one near miss or adverse event.  A more recent publication of voluntary reporting of adverse events at a teaching hospital, demonstrated an average of 3-4 errors a week at this institution.

VIN Quick Polls to look at medical errors in veterinary hospitals

In 2019, several Quick Polls on VIN were used to start to explore the issue of medical errors in veterinary hospitals.  Quick polls are one question surveys that live on the front page of VIN for one week at a time.  If you participate, you can view the results as they accumulate.  All VIN members have access to the results in the Quick Poll archives and in VIN This Week, the following week.

Because the surveys are voluntary and the questions can be viewed before you choose to answer, there is selection bias.  The people who are likely to answer each question are potentially more likely to either have experienced the problem or to be worried about the issue. However, these short surveys provide preliminary knowledge that can be used for designing more rigorous research in the future.

What do veterinarians know about medical errors?

The first question asked was:

I do not remember having any course work or discussion about medical errors during veterinary school so I was glad to see training is occurring in some locations.  However, I believe patient safety and how to respond to medical errors should be an important part of every veterinarian’s training.

How do veterinarians respond to medical errors?

After I wrote the vaccine error blog and discussed system changes, Dr. Corp-Minamiji of VIN suggested we ask how others respond to errors in their practices.

Our first question was:

Our second question was:

Thoughts on these surveys of medical errors

Several items on these surveys stand out to me.  First off, vaccine and medical errors are happening in our hospitals. It is a real problem that is impacting us and our patients.

Second, in the majority of cases, our response is either to just be more careful or not to change anything.  Our practices are busy and it is hard to sit down and make time to really investigate WHY errors happen and HOW we might meaningfully change things to decrease the risk of them happening again.

What are some ways to prevent vaccine and medication errors?

People focused changes are less effective

As seen in the chart, a suggestion to be more careful is unfortunately one of the least effective actions. After a mistake, everyone is more careful but it is hard to be hypervigilant all the time.

Education about the risk of vaccine and medication errors might be more helpful.  I like teaching the 6 Rs (“rights”) of medication administration (which also applies to vaccines) and the triple check.  The 6 Rs are:

• RIGHT PATIENT
• RIGHT DRUG
• RIGHT DOSE
• RIGHT ROUTE
• RIGHT TIME
• RIGHT DOCUMENTATION

The Prescription triple check:

• When you remove the medication from the shelf and match it to the prescription label, treatment sheet or order sheet
• When you draw up the medication or count pills into a vial, check the bottle against the prescription label or treatment sheet again
• Before you give the medication to the patient, check the prescription label or treatment sheet again.

This is a great article on safe medication administration and more details about the 6 Rs.

In my previous hospital, these were part of our training and the 6Rs were also posted in our pharmacy as a reminder.

Double check systems (two people confirm the 6 Rs) are useful but do add time.  I think they are valuable especially in high risk situations.  I strongly recommend double check systems for chemotherapy and opioid pain medications.

Checklists have a clear safety benefit for surgical patients, both in human medicine and in veterinary medicine. Certainly, adding the 6 Rs to a training checklist for staff is very valuable. A training checklist on vaccines that specifically discusses the risk of oral vaccines subcutaneously can help make staff more aware of the mistake risk.

System focused changes can be more effective

Standardization can help especially with drug dosage issues.   In an interesting 2018 abstract from the University of Florida, drug dosing errors due to misinterpretation were significantly reduced by implementation of a standard drug order format.  In this setting, having all doctors order drugs always as “drug name, milligram dose, frequency, route,” rather than sometimes in milliliters, sometimes as a dosage in mg/kg, or sometimes as mg/lb, increased safety for patients.

Automation is uncommon in medication ordering in veterinary medicine.  However, there are now electronic ICU treatment sheets that include warnings if you order a subtherapeutic or toxic drug dose.  It will not prevent you from giving the medication but it does help protect against calculation errors.

Creating veterinary oral vaccines that do not require a needle to reconstitute would be an example of a forcing function – it helps to eliminate part of the reason the mistake occurs.

Interested in learning more?

If you are a VIN member, this is a link to a VIN Rounds I did on responding to adverse events and medical errors.

Zero Harm in Healthcare was just published this month in NEJM Catalyst

Patient Safety Network has a good article on Medication Errors and Adverse Drug Events

Thank you to Dr. Christy Corp-Minamiji and the VIN Quick Poll team for the VIN Quick Polls