A recent work event made me think again about how we make our hospitals safer for pets
The Error
A couple weeks ago, I worked a relief shift at one of my favorite hospitals in the area. The hospital has a great flow, kind and well-trained staff, and an excellent clientele. I always feel welcome and proud of the quality of care provided to pets and clients.
On this particular day, my second appointment was a standard annual exam and vaccines. After I spoke to the owner, the dog was brought to the treatment room for its 3 vaccines. Two vaccines were given and the staff member suddenly stopped, turned pale, and said, “I gave the DAPP by mouth and injected the oral bordatella subcutaneously.”
Emotions
I spend a lot of timing writing and teaching about medical errors in veterinary practice. I recently did a VIN/VECCS webinar on “When the Worst Happens: Responding to Medical Errors.” I hate mistakes and when the staff member let me know what happened, I felt that horrible nauseous, sinking feeling in my stomach. My first question, of course, “Are you sure?” I wanted it not to have happened, not to be true, but the mistake had been made.
Action: Patient always comes first
I took several deep breaths and then we immediately called the vaccine manufacturer to figure out possible consequences and any needed action. I then got onto VIN, an amazing resource in this type of situation, to see what else I could learn.
Second: Honest conversation with the client right away
Once, I had the information from the vaccine manufacturer and from VIN, I spoke to the other veterinarian in the hospital so I knew the procedure for this kind of problem. Then, I went to speak to the owner.
I told them what had happened, what the risks were, and how we were going to proceed. We drew the baseline bloodwork at no cost, charged nothing for the visit, set the client up for the appropriate rechecks and repeat vaccines (also at no cost). We set up reminder follow up phone calls so that we could check in on the patient frequently. I apologized profusely and assured them we would do every thing needed to make sure their pet was OK.
But this is not the first time
Many people in this situation would be mad at their staff. They might plead with people to be more careful in the future. However, after I got off the phone with the vaccine manufacturer and off of VIN, I realized that this mistake happens ALL THE TIME. A VIN search showed far more of this type of mistake than what should happen.
Who is to blame for this mistake that could cause abscesses under the skin or possible liver complications?
How often does this happen?
Most people do what I do and call the vaccine manufacturer. However, some people call the ASPCA for help. According to Dr. Tina Wismer, medical director at ASPCA Poison Control, they received 18 calls in the past year of oral bordatella being given subcutaneously. There are 36 separate posts about bordatella vaccines being given by the wrong route on VIN.
Why did this mistake happen?
When mistakes happen in your hospital, it is important to not only deal with the problem in the moment, but also to attempt to prevent it in the future. Our oath requires us to “do no harm”
The first thing is to try understand WHY it happened. It is easy to say, “we were going too fast,” “we weren’t careful enough,” but those things will happen again, despite our best efforts to always be diligent.
Vaccine design flaws
So, why do staff get mixed up and give a vaccine that should be by mouth into the skin? This oral vaccine has to be reconstituted using a needle and syringe. Thus, both your injectable vaccines and your oral vaccines have needles which makes a mistake more likely.
In addition, this oral vaccine is very similar in color to the injectable vaccines. The vaccine label is small and although it says oral, the lettering is so small that it does not catch your eye.
In addition, when you tear the label off to put on the syringe, the “oral” wording stays on the bottle.
Systemic Changes
The chart below shows improvements that can be made in “mistake-proofing” and their effectiveness from low to high.
People Focused Responses to Prevent Errors
As seen in the chart, a suggestion to be more careful is one of the least likely things to be effective. Education about the risk of this mistake and why it might occur is somewhat more helpful. Checklists and double check systems work better than either of these. Because they do add some time, we often use them in situations with devastating consequences. I strongly recommend double check systems for chemotherapy. Checklists have a clear safety benefit for surgical patients, both in human medicine and in veterinary medicine. Certainly a training checklist for staff on vaccines and specifically discussing risk of oral vaccines subcutaneously can help in making sure everyone has this information.
System Focused Responses to Prevent Errors
System focused responses look at the way our products and hospitals are organized in an attempt to “mistake-proof”
In this situation, you could start with a policy around vaccine administration that says vaccines are reconstituted in a certain area and never brought to the patient without oral vaccines having the needle removed. Another possibility would be in house labels that say ORAL on a red background and placed on the syringe.
Examples of fool proof systems
However, product design can play a part in error prevention. For example, Intranasal FVRCP is slightly better than oral bordatella in that it comes with pipettes and instructions for reconstituting without a needle.
Error is still possible as you can use a needle to reconstitute. But what if the Bordatella oral was instead packaged like the human oral rotateq vaccine for infants? Watch this video to see the packaging that never involves a needle and thus there is no way to inject by mistake. The rotateq vaccine design is the most effective way to prevent this problem because it simply eliminates the risk.
Push Manufacturers for Safety Improvements
I strongly encourage the veterinary vaccine manufacturers to not simply accept that mistakes will happen. Instead, lets try to eliminate the risk. I urge companies such as Zoetis, Merck, Fort Dodge and BI to look at the oral bordatella design issues. Let’s manufacture oral or intranasal vaccines that don’t require a needle for reconstitution. At the very least, the ORAL or INTRANASAL label should be big, in red, and not stay on the bottle when you peel.
It is our duty as veterinarians to safeguard our patients. Let’s work together to identify and eliminate safety risks to our patients.
