Reducing veterinary medication errors: Four important actions

Most healthcare workers, human and veterinary, have witnessed or been a part of a medication error.  A 2012 human study estimated that preventable adverse drug events from injectable medications alone impact 1.2 million hospitalizations every year in the US.   While most medication errors may not cause harm, a 1993 study estimated that at least 7000 people each year die from these events.

Veterinary medication errors

During my career, mostly in 24/7 referral centers, I have seen a lot of veterinary medication errors.  Similar to human studies, most have caused no harm.  I’ve seen patients get cefazolin twice when nurses were trying to help each other and forgot to sign the treatment sheet.  I’ve seen a dog get an oxymorphone overdose when a doctor made a 10x math error but it was caught quickly and reversed.

However, in another case, a cat was referred for care of acute kidney injury.  She had been accidentally sent home with a dog’s carprofen prescription.  The owner diligently gave these large pills for several days before the error was recognized.

In an even sadder case, a cat presented for severe weakness.  He was found to be very anemic and to have severe bone marrow suppression.  As I delved into the history, I discovered that a human pharmacist had misread a veterinary prescription and sent home azathioprine (which is extremely toxic to cats) instead of azithromycin (an appropriate antibiotic).

Why do Medication Errors Happen?

It is easy to blame these errors on inexperienced help or someone not paying attention.  However, I’ve seen mistakes involving incredibly experienced and competent people. They happen not only in ER, but also in specialty departments, and in primary care practice.  We work in complex environments, people are expected to multitask, and “to err is human.”

Errors are SYSTEM PROBLEMS not HUMAN PROBLEMS

For years, the response in human medicine to any mistake was to blame the PERSON involved.  However, this never solved the problem because when you look closely at these situations, anyone might have made the same mistake in the same circumstance.  I have in fact seen numerous nurses in multiple hospitals double-dose cefazolin when a system was not set up to assign nurses specific patients for care.  A 10x overdose is sadly common either with doctor or nurse calculations when no double check system exists.  These situations happen more in the middle of the night, when we are busier than expected, or when the system is not clear.

In the case where azathioprine was dispensed, it was a hand-written prescription that was hard to read.  The pharmacist should have called the veterinarian back but, it was the end of the day, the client had arrived, and so he filled what he thought he read.  Have you ever “interpreted” a written medical record or doctors note? Have you ever made an assumption especially when trying to finish your work day?

How do you “Mistake Proof”?

It is easy to get discouraged in the face of human foibles.  However, studies show that taking a SYSTEMS APPROACH can decrease these errors.  In a study done by Virginia Mason Healthcare, medication errors were decreased 5-fold over a 3-year period by emphasizing safe medication practices, by decreasing interruptions of nurses during medication preparation, and by reorganizing how medications were stored.

Here are four important actions to improve veterinary medication safety in your hospital.

1) Make Safe Medication Practices part of your training for ALL new DOCTORS and STAFF

What are safe medication practices?  In human healthcare, the 6 Rs (“rights”) of medication administration and the triple check are taught.  The 6 Rs are:

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

Every time a prescription is made up and given, it should be checked 3 times (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, we made these not only part of our training but also posted a laminated list of the 6Rs in our pharmacy as a reminder.

2) Minimize Interruptions and distractions when staff are handling medications

It is crucial to realize the real impact of interruptions and distractions.  In a study at Kaiser in San Francisco in 2006, nurses wore an orange vest to signal that they were giving medications and thus should not be interrupted.  The nurses initially hated the vests but staff learned to not interrupt them while they were preparing and giving medications and at the end of the study, medication errors had fallen by 47%!    If you are a veterinarian, how often do you interrupt your nurses while they are making up a CRI or giving medications? Are there ways to change your flow so no one gets interrupted while filling a prescription?

3) Beware of Medications that look alike or sound alike

Medication errors can also occur when medications that look too similar are stored next to each other, are not well labeled, or if safety and reconstitution information is not readily available.

Take a look at your hospital – are there medications that look similar that could be mistaken right next to each other?  Two common errors that I have seen that could be minimized with better storage and better delineation:

• Mark Insulins VERY CLEARLY for which are U-100 and which are U-40.  DO NOT store the different insulins in the same bin in the refrigerator.
• Convenia® and Cerenia® are two medications that sound alike, come in similar size bottles and are often stored in the refrigerator next to each other.  I know of several errors in different hospitals where a patient needing Convenia® was given Cerenia® or vice versa.

4) If a medication error occurs in your hospital, INVESTIGATE to find ways to MISTAKE PROOF

The only thing worse than a bad medication error in your hospital is having the same thing happen more than once.  It is important to talk openly without blame about these incidences.  Talk instead about how to PREVENT them in the future.

By working as a profession to address medication errors, we improve the quality of care we provide to pets and their people.

Good information on reducing veterinary medication errors and reducing your own risk of experiencing a medication error:

https://www.fda.gov/drugs/resourcesforyou/consumers/ucm143553.htm