Case Studies (TX)

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Case Study 1:

History/Presentation:

5 year old, F/S, West Highland Terrier
New client/new patient
Lameness evaluation left pelvic limb, 1 week duration
Lameness first noted after jumping to fetch a Frisbee at the beach
Current medications: Ivermectin/pyrantel pamoate monthly chewable, afoxolaner monthly, 25mg Tramadol PO at bedtime.
Patient is current on rabies vaccination, dhpp vaccination, bordatella vaccination, heartworm test, fecal examination, and leptospirosis vaccinations.
No prior major medical hx.

Weight: 18.4lbs, Temp: 101, Pulse: 126, Resp: 24

BAR: p/m=mm: CRT<2s, PLN = N
H/L: NMNA, lungs clear bilaterally. ABD = soft, non-tender, no grossly palpable abnormalities
EENT = Oral exam limited, patient snapping, muzzled. Eyes are clear and bright w/ no discharge. Ears are clean, no debris or inflammation appreciated. Tracheal cough not elicited. UG = external genital organs appear normal. No palpable urinary bladder. MS/SKIN = Ambulatory x 4 with toe touching lameness of the L rear leg. Unable to palpate fully or fully assess for swelling or range of motion, fractious. Neuro = brief, nsf. BCS 6/9. PA 2/5.

Sedation is recommended for more complete examination of the affected limb and for radiographic evaluation due to pain response and snapping behavior by pet. Sedation is delayed until laboratory evaluation is complete.

Complete Blood Count (in-house laboratory analyzer):

WBC: 8.770 10^3/ul -range 6-17
RBC: 6.02 10^6/ul -range 5.5-8.5
HGB: 14.450g/dl-range 12-18
HCT: 43.930% range 37-55
MCV: 68.000fl -range 60-72
MCH: 22.79pg- range 19.5-24.5
MCHC: 33.74g/dl-range 34-38
RDW: 13.92% -range 12-16
PLT: 354 10^3/ul -range 200-500
MPV: 8.71 fl -range 6.1-10.1

CHEM:
ALB: 3.2g/dl-range 2.2-3.9
ALKP: 183 U/L-range 14-192
ALT: 100 U/L-range 12-115
AMYL: 700U/L- range 500-1400
BUN: 23 mg/dl-range 16-33
CA: 10.9mg/dl-range7.9-11.3
CHOL: 183 mg/dl-range 62-191
CREA: 0.900mg/dl-range 0.6-1.6
GLU: 118 mg/dl- range 77-153
PHOS: 6.3 mg/dl-range 4.5-10.4
TBIL: 0.10mg/dl-range 0-0.9
TP: 6.6g/dl-range 5.2-8.2
GLOB: 3.8 g/dl-range 2.8-4.8

Sedation:
Butorphanol 10mg/ml 0.18ml IM
Dexmedetomidine 0.1mg/ml 0.52ml IM

Sedation is swift and profound.

Respiratory Arrest:
mm=pale/tacky; CRT > 3s; thready femoral pulses; HR 18; SpO2 = 72.

Emergency procedures implemented:
IVC, cephalic, 20g.
LRS ¼ shock dose bolus
Manual ventilation
Atipamezole 5mg/ml 0.52ml IM
Naloxone 0.4mg/ml 0.83ml IV
Good response, return of spontaneous respirations, improved perfusion
Extubated and sitting up at 8 minutes.

The owner is notified immediately of anesthetic incident, and advised that due to resuscitation procedures no radiographs or musculoskeletal exam were performed.
Owner requests her records be transferred at the time of discharge.

Anesthesia technician informs attending veterinarian that she drew up dexmedetomidine 0.5mg/ml 0.52ml, instead of dexmedetomidine 0.1mg/ml 0.52ml IM.

Definitive diagnosis is not obtained due to anesthetic emergency/respiratory arrest/resuscitation measures.
R/O: Anesthetic complication vs. Sedative overdose
R/O: Cranial Cruciate Ligament injury, Medial Luxating patella, soft tissue injury, foreign body within the paw pads, and fracture.

Summary

In this case, an anesthetic emergency occurs, a diagnosis is not obtained, and a veterinarian client patient relationship is terminated as a result. As we all know, anesthetic incidents can occur for no apparent reason and with no wrong doing on the part of anyone involved. However, in this situation, there is sufficient concern that a veterinary medical error may have contributed to the anesthetic incident. At the very least, the veterinarian and owner of the veterinary practice have a moral and ethical obligation to analyze this event and provide a plan for preventing such an error in the future. A Root Cause Analysis will provide a frame work for the analysis of this incident, as well as help to develop a plan for preventing such incidents in the future. The focus of this course is the prevention of medical errors in veterinary practice, not the legal implications and proper handling of such an incident from a legal perspective. For this reason, recommendations will be focused only on analyzing how the incident occurred and techniques for preventing similar errors in the future. No comment will be made on the handling of client communication or legal consultation regarding the error. It should be noted that consultation with your liability provider and/or having a practice protocol for handing communication with the client is recommended.

Root Cause Analysis:

  1. Define the problem
    1. What do you see happening?
      Anesthetic complication.
    2. What are the specific symptoms?
      Poor perfusion. Hypoxemia. Severe Bradycardia, Respiratory Arrest.
  2. Data Collection
    1. Everyone must understand the problem, before it can be analyzed.
    2. Include everyone that can add information from the front desk to clinicians to help gain a better understanding of the problem.
      Attending veterinarian, CVT, personal manager/office manager.
  3. Identify or chart causal factors
    1. What order of events lead to the problem?
      A fractious patient was given a sedative for a sedated exam and radiology procedure. The patient went into respiratory arrest after the sedative was administered. The patient was resuscitated. A technician informs the attending veterinarian that she inadvertently gave 4x the ordered dose of dexmedetomidine.
    2. What conditions allow the problem to occur?
      Remember to employ the “5 Whys” when identifying causal factors, and that there may be more than one causal factor.

Patient was given 4x more dexmedetomidine than the veterinarian wrote the orders for.
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WHY?

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CVT A did not know that there were 2 available concentrations for dexmedetomidine in the hospital.

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WHY?

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The hospital recently received dexmedetomidine 0.1mg/ml, in addition to the normal dexmedetomidine 0.5mg/ml that they have always carried. Staff and Doctors were notified at the last staff meeting, but CVT A was not present at the last meeting.

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WHY?

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CVT A was ill and had an approved sick day on the day of the meeting. No steps were taken to ensure that CVT A was brought up to speed on the staff meeting she missed.

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WHY?

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Syringes were only labeled with a drug name and not a drug concentration, and the concentration was not verified by attending veterinarian before administration.

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WHY?

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There is no formal protocol or training checklist for labeling syringes with the practice.

4. Root Cause Identification – the identification of the underlying reason or reasons for each causal factor.

Why does the causal factor exist?

  • There is no existing protocol for minutes, or review of minutes, when a staff member or doctor misses a meeting.
  • No existing training protocol for injectable medication handling and administration for technicians or Doctors within the practice.
  • Human factors/error; failure to follow safety checklist prior to administering injectable medication.

What is the real reason the problem occurred?

  • Technician should have been brought up to speed on staff meeting she missed.
  • Injectable medication administration safety and procedures should be reviewed with doctors and technicians within the practice.
  • Safety checklists are extremely important in reducing the contribution of human factors to medical errors.

5. Generate and Implement Solutions

  • Personal Manager/Office Manager will write and present a formal protocol for minutes and attendance to be taken at staff meetings. Personal manager will also develop a formal protocol for review, and documentation of this review when a staff meeting or doctor misses a staff meeting.
  • Medical Director will write and present a formal training on protocol for injectable medication handling and administration checklist. This will be presented at a mandatory staff meeting. This will include checklists for handling, labeling, documenting, and administering injectable medications within the practice.
  • Both the protocols will be presented at a mandatory staff meeting, and then become a part of the practice protocols handbook that is to be updated and reviewed by all staff and doctors annually.

Conclusion:

As with most problems that face veterinary practices and practitioners, the problem. in this case, is multi-factorial and fluid, often involving not only a technical error but also a communication error. There is a learning curve, and there is not a one size fits all solution for every problem. In this case study, the management learned a valuable lesson about communication within the practice. Although the practice should be commended for having regularly scheduled, mandatory staff meetings, they had no formal protocol in place for communication and documentation of the information provided and covered in those meetings. The staff and veterinarians were made aware of the new dexmedetomidine concentration stocked at the practice at one of these meetings, but documenting this information, and communicating this information to a missing staff member was overlooked. The new protocol for taking attendance and minutes at the meeting addresses this. Not only are attendance records and minutes taken by a designated staff member, but any staff member that is not in attendance, must review the minutes and sign off that they have done so within 24 hours of returning to work.

Some might argue, that it shouldn’t matter that the technician missed the meeting, as drug concentrations should always be verified before drawing them into a syringe for administration. This is where human error factors into the equation. Human errors occur, and one of the most effective ways to decrease human errors is training and checklists. Many questions exist that should be reviewed as listed below:

  • Have all of the technicians in the practice been trained on the mental and physical steps they should take when preparing medications for administration?
  • Was the technician distracted by a treacherous case load, by a grouchy veterinarian, by something weighing on her outside of work, or by a dysphoric and loud animal in the ICU?

Technicians and veterinarians alike need constant training and review on not only the technical aspects of their positions, but how to balance their case load, and how to balance life with their emotional and physically draining positions. Although, technicians and veterinarians draw medications and vaccinations into a syringe for administration hundreds to possibly even thousands of times a week, complacency must be avoided.

  • What is the drug you are pulling up?
  • What is the concentration of the drug?
  • What is the appropriate dosage of the drug?
  • What is the dose ordered?
  • How is this drug administered?
  • Is the syringe correctly labeled with the name and concentration of the drug?
  • Has the drug, concentration, route of administration, and time been accurately recorded in the patient’s record?

This mental checklist should go through a technician and veterinarian’s mind for every single medication, no matter how innocuous or benign a drug may seem. The practice in this case study has elected to review these steps and document a formal checklist for medication handling and administration. This case study specifically illustrates why this training is important for the veterinarian as well as the technicians. Although, the technician was not aware of the new concentration of the dexmedetomidine, and did not label the syringe with the concentration, the veterinarian WAS aware of the two available concentrations, and did not question the concentration in the unlabeled syringe. The technician was inconsolable and felt that the blame for this medical error fell on her shoulders, but the error could have been prevented if the attending veterinarian had verified the contents of a syringe that was not completely labeled, or queried the technician on whether she was aware of the two different concentrations of dexmedetomidine in the hospital.

  • Why didn’t the veterinarian verify the contents of the syringe?
  • Was the veterinarian complacent because he was familiar and comfortable with the technician?
  • Was the veterinarian multi-tasking a heavy case load?
  • Was the veterinarian thinking about something outside of work?

There is no easy answer here and there may have been more than one of these factors at play in the equation. The answers provided by the Root Cause Analysis have formed the basis for an action plan to raise awareness of the error and created a platform for formal protocols to help prevent similar errors in the future.

 


 

Case Study 2:

History/Presentation:

7 year old, neutered male, Labrador retriever
New client, new patient, evaluation of possible hip pain
Client reports that the pet seems very slow getting up and down, and will no longer use the stairs at their home.
Current medications: Monthly ivermectin/pyrantel chewable, monthly afoxolaner, and an unknown antihistamine for skin allergies. Antihistamine dispensed by previous veterinarian.
Records have been requested from previous DVM. Only vaccination history has arrived.
No prior major medical history, other than skin allergies.

Weight: 78.4 lbs, Temp: 102.3, Pulse: 112, Resp: pant

BAR, p/m=mm, CRT<2s, PLN – N, H/L = NMNA, lungs clear bilaterally, ABD = soft, non-tender, no grossly palpable abnormalities. EENT = moderate sclerosis OU. Ears clean, free debri, but skin thickened w/ mild stenosis noted AU. No tracheal cough is elicited on tracheal palpation. Grade 1 dental disease is noted, UG = bladder is not palpable. External genital organs are visually normal. MS/SKIN = ambulatory x4, very slow to rise in the rear legs, moderate muscle atrophy over the hips and thighs, reduced range of motion in both hips, right worse than left. Stifle palpation is unremarkable. Hair coat is dull and brittle throughout. Skin is dry and scaly throughout, Neuro = brief, nsf. BCS = 8/9. PA = 1/5.

R/O: OA, DJD, dysplasia, neoplasia, open.

Recommend cbc/chemistry panel/radiographs.
Estimate approved by client.

CBC (in-house analyzer):

WBC: 15.770 10^3/ul -range 6-17
RBC: 7.02 10^6/ul -range 5.5-8.5
HGB: 14.450g/dl-range 12-18
HCT: 41.930% range 37-55
MCV: 68.000fl -range 60-72
MCH: 22.79pg- range 19.5-24.5
MCHC: 33.74g/dl-range 34-38
RDW: 13.92% -range 12-16
PLT: 315 10^3/ul 200 – 500
MPV: 8.71 fl -range 6.1-10.1

CHEMISTRY (in-house analyzer):

ALB: 2.9g/dl-range 2.2-3.9
ALKP: 192 U/L-range 14-192
ALT: 118 U/L-range 12-115
AMYL: 1100U/L- range 500-1400
BUN: 27 mg/dl-range 16-33
CA: 9.9mg/dl-range7.9-11.3
CHOL: 346 mg/dl-range 62-191
CREA: 1.1mg/dl-range 0.6-1.6
GLU: 109 mg/dl- range 77-153
PHOS: 5.3 mg/dl-range 4.5-10.4
TBIL: 0.20mg/dl-range 0-0.9
TP: 6.4g/dl-range 5.2-8.2
GLOB: 3.4 g/dl-range 2.8-4.8

Radiographs:

Significant subluxation of the coxofemoral joints bilaterally.
Remodeling femoral head and neck bilaterally.
Osteophyte formation left acetabular rim.

Diagnosis:

Moderate hip dysplasia, with degenerative joint disease bilaterally.
Overweight

Plan:

    • Dispense: Carprofen 75mg, #60, 1 PO BID
    • Dispense: Tramadol 50mg, #60, 1-2 PO BID-TID
    • Joint supplement declined
    • Weight management diet declined
    • Recheck exam and weight in 14 days.

Update:

No show for recheck appointment.
Tech PCTO to reschedule: Client is very upset that pet has been treated at local emergency center for bleeding gastric ulcers. Client reports that her previous veterinarian advised her that the carprofen we dispensed was dangerous when given with the “antihistamine” that pet was already taking. Client reports the antihistamine that pet was already taking is prednisone. The client does not wish to reschedule their recheck appointment.

Summary

In this case, it was determined that the pet suffered severe gastric ulceration, secondary to concurrent prednisone and carprofen administration. The owner was under the impression that the prednisone she had been administering to the pet was an antihistamine, not a steroidal. As with the previous case study, our focus here is the medical error, and prevention of future medical errors, not liability or communication with the client about the error. Again we will use a root cause analysis to find ways to prevent future errors of this type. It is very easy, and very tempting to place blame on the client for stating the pet was only on an antihistamine, but our focus is what we can do within our own practice to prevent errors, regardless of influences outside the practice.

Root Cause Analysis:

  1. Define the problem
    1. What do you see happening?
      A Non-steroidal anti-inflammatory (NSAID) was administered concurrently with a steroidal anti-inflammatory (SAID), a direct contraindication.
    2. Are there specific symptoms?
      Severe gastric ulcerations are reported, but renal impairment and hepatopathy are also possible. Records are not currently available from the emergency clinic, per owner’s directive.
  2. Data Collection
    1. Everyone must understand the problem, before it can be analyzed.
    2. Include everyone that can add information from the front desk to clinicians to help gain a better understanding of the problem.
      Attending veterinarian, CVT, reception staff, personal manager/office manager.
  3. Identify or chart causal factors
    1. What order of events leads to the primary problem?
      New client/patient exam to establish, diagnostic evaluation, hip dysplasia and DJD diagnosed, carprofen and tramadol were prescribed and dispensed. Client did not show up or reschedule follow up visit. Client advised technician of the complications at follow up phone call regarding the missed office visit.
    2. What conditions allow the problem to occur?
      Remember to employ the “5 Whys” when identifying causal factors, and that there may be more than one causal factor.


The new patient developed gastric ulcers after receiving treatment at the new practice.

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WHY?

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The attending veterinarian administered an NSAID while the animal was taking a SAID.

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WHY?

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The attending veterinarian was unaware that the new client had been prescribed a SAID by former practice.

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WHY?

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No one from the new practice contacted the former practice for medical records.

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WHY?

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The owner informed attending veterinarian that the animal was on an “antihistamine”.

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WHY?

The client did not know that the animal was actually prescribed prednisone for skin allergies, and that prednisone is a steroid, not an antihistamine.

4. Root Cause Identification – the identification of the underlying reason or reasons for each causal factor.

Why does the causal factor exist?

  • No formal protocol for following up on medical records received from other practices.
  • No formal training or protocol for medical records within the practice. All reported medications were not verified and charted.

What is the real reason the problem occurred?

  • Lacking staff training and practice protocols
  • Human error

5. Generate and Implement Solutions

  • A formal presentation on this case will be presented to all staff and doctors at a mandatory staff meeting. The discussion will focus on including the name, dose, and frequency of all medications a pet receives in the medical record, even if that medication is OTC, nutraceutical, or dispensed by another hospital. This step should be started by the technical staff when they have the initial meeting with clients in an exam room, but ultimately, it is the responsibility of the veterinarian to ensure that this occurs.
  • A formal checklist will be created for the reception staff and technical staff for collection of medical records prior to a new client/patient visit. Ultimately, it is the responsibility of the attending veterinarian to verify that this has occurred, and to review these records prior to instituting treatment.

Conclusion:

This case study again illustrates the multi-factorial nature of most medical errors. In this case, it is very easy to point the finger at the client who stated the pet was on an antihistamine, but it is important to remember that we cannot place blame on someone with no medical knowledge for a medical error. We also must remember that it is not uncommon for clients to perceive a steroidal medication used as treatment for allergies as an “antihistamine”. We must make proper protocol for medication labeling a MUST for every veterinary practice. This case is a classic example of the perfect storm. Despite the fact that the client gave invalid information, and that the client’s previous veterinary did not provide appropriate education, labeling, and warnings when a steroid was dispensed, it was ultimately the attending veterinarian’s responsibility to ensure that complete medical records were obtained, or that at the very least that the client’s previous practice was contacted to get information on the “antihistamine” that was dispensed. A good rule to live by when you are the attending veterinarian is “Trust, but verify”. It is ok to “ trust” your clients, and you should “trust” staff, but you should always “verify” what they are telling you, and what they are doing. As with most case studies that involve a medical error, the analysis of this case study will provide a platform for multiple, educational presentations to the staff and doctors.

Although this practice has excellent practices for labeling, discussing, and documenting medications that they dispense, it is a topic that should be reviewed with staff, and a checklist provided and implemented to ensure that these practices are adhered to at all times. Despite the fact that the client’s misunderstanding of the dispensed medication occurred at the previous veterinary practice, it still provides an excellent opportunity for the current practice to provide a staff training and prevent similar errors in their own practice. Many practices have implemented the use of warning stickers on all prescription bottles. For example, a sticker that says, “This is a steroid, do not administer this medication with any other steroids or non-steroidal anti-inflammatories”. You can order pre-printed labels from your distributor, you can request custom labels, or you can include drug information in the directions that you type on the label, ie: “this is a steroid”. Client consultation on the medication, side effects, and proper use, should also always be documented in the medical record. Many practices have also instituted protocols for written discharge instructions, and documentation that these discharges were provided to the client, and that the client acknowledges understanding of the provided materials. Whatever protocol your practice decides on, it should be written, documented, and presented at a mandatory staff meeting.

Similarly, the need for a protocol regarding obtaining medical records from a client’s previous veterinarian’s practice is highlighted in this case study. A protocol that provides fail safe verifications along the way is often the best approach with this problem. Staff should be trained to begin seeking the medical records as soon as the client makes the appointment. If the records have not arrived by the time the client arrives for their appointment staff should repeat their request, and if the medical records are still not available a technician or veterinarian should contact the practice directly to verify any current medical history or medications. Again, the responsibility ultimately falls on the shoulders of the veterinarian to verify that this has occurred, but a written protocol and documented staff training can make the verification process much easier for the veterinarian.

 


 

Case Study #3:

History/Presentation:

12 years old, F/S, Yorkshire Terrier, prescription refills requested by phone
Weight 11.5lbs.
History of valvular heart disease. Under the care of local cardiologist, with follow ups through primary veterinarian’s practice, as directed by the cardiologist.

Refills requested:
Benazepril 5mg, ½ tablet, by mouth, every 12 hours.
Furosemide 12.5mg, 1 tablet, by mouth, in the morning. ½ tablet, by mouth, at bedtime.
Pimobendan 2.5mg tablets, ½ tablet, by mouth, every 12 hours.
Client requests a three month supply of each medication, due to travel plans.
Refill requests are approved by attending veterinarian, and filled by pharmacy technician. Owner is notified that medications are ready for pick up.
The refills are appropriately documented in the medical record, as are the conversations with the client.

PCFO: Owner reports that one of the medication refills she picked up 3 days ago appears to be a different tablet than usual. Owner has not yet started administering the refills. Owner reports it is the benazepril tablets that appear different than usual. Call referred to pharmacy technician. Pharmacy technician advises owner that it is not unusual for tablets to appear differently, especially when generics are used, as is the case with benazepril. This call is NOT appropriately documented in the medication record.

PCFO: Owner reports that she began giving the new medications 3 days ago, and since then pet has been drinking and urinating frequently. Technician speaks to owner, and advises that increased thirst and urination can be an expected side effect of furosemide administration, but offers an exam with the doctor that afternoon, or a follow up phone call from the veterinarian. Owner declines to come in for exam, but would like a return call from the veterinarian. Owner notes that she is specifically concerned that pet’s furosemide dose has been unchanged for months, and now the thirst and urination seems to have increased dramatically.

Emergency walk-in presentation, the following morning:

Owner concerned that pet is weak, lethargic, inappetent, and her respirations appear very shallow.
Owner notes increased thirst and urination of 3 days duration, but now pet is not urinating at all. Owner further notes that the symptoms began when she began administering the new prescription refills.
Owner notes ongoing concern that the benazepril refill that she received appears different than usual. Owner brought the prescription refills with her.
No v/d/c/s.

T=97.5, P=162, R=72, CRT >3s, mm=injected, bright pink, tacky

H/L: GIII-IV/VI systolic murmur, best heard left thorax. Respiratory character is quick and shallow. Mild wheezes are audible, but no crackles appreciated.
ABD: Tense, not appreciably tender. Moderate to severe abdominal component to respirations.
EENT: Moderate lenticular sclerosis OU. GI/IV dental.
PLN: N
UG: No palpable bladder.
MS/SKIN: Non-ambulatory, able to stand briefly if assisted, but quickly tires and collapses.
Neuro: dull
BCS 2/3. PA 0/5

Tachypnic, Tachycardic, dehydrated, respiratory distress hx PU/PD, hx of stable cardiac disease

CBC:

WBC: 17.680 10^3/ul -range 6-17
RBC: 9.6 10^6/ul -range 5.5-8.5
HGB: 18.450g/dl-range 12-18
HCT: 64.930% range 37-55
MCV: 68.000fl -range 60-72
MCH: 22.79pg- range 19.5-24.5
MCHC: 33.74g/dl-range 34-38
RDW: 13.92% -range 12-16
PLT: 515 10^3/ul – range 200-500
MPV: 8.71 fl -range 6.1-10.1

CHEM:

ALB: 4.9g/dl-range 2.2-3.9
ALKP: 210 U/L-range 14-192
ALT: 225 U/L-range 12-115
AMYL: 1100U/L- range 500-1400
BUN: >180 mg/dl-range 16-33
CA: 12.9mg/dl-range7.9-11.3
CHOL: 346 mg/dl-range 62-191
CREA: 6.4 mg/dl-range 0.6-1.6
GLU: 109 mg/dl- range 77-153
PHOS: 12.5 mg/dl-range 4.5-10.4
TBIL: 0.20mg/dl-range 0-0.9
TP: 9.0 g/dl-range 5.2-8.2
GLOB: 5.2 g/dl-range 2.8-4.8

USG: 1.018

Severe azotemia, hemoconcentration, hypovolemia, pre-existing cardiac disease
R/O: Pre-renal on renal azotemia

After discussion with the owner of laboratory findings, clinical impressions, and difficulty of treating concurrent renal failure w/ cardiac disease, the owner again raises the question of the different appearance in the medications she recently picked up.

Using a pill identifier web site and comparison with the hospital stock medications it is learned that that 20mg furosemide tablets were incorrectly dispensed in the benazepril bottle. Pet has been receiving her normal 12.5mg furosemide AM and 6.25mg furosemide PM, and the addition of 10mg furosemide BID from the incorrectly labeled benazepril bottle.

Owner is notified of the mistake. Owner requests referral for treatment at the local 24/7 specialty facility. Owner declines initial stabilization before transfer. Owner signs an AMA before transfer. Attending veterinarian notifies specialty facility of the referral and sends medical records prior to owner’s arrival at the facility.

Patient deceased on arrival at the specialty center.
Necropsy declined.

Owner returns to the primary veterinarian’s office for body care and requests a consultation with the attending veterinarian immediately.

Summary

As discussed previously, the focus of this course is medical errors, not the communication of errors to the client or the legal implications of such errors, it does however warrant noting that a situation such as this must be handled with empathy and care, and sharing action plans to prevent similar errors in the future with an owner are often an important part of repairing the relationship with an owner affected by a medical error. Having the opportunity to sit down and discuss this case with a previously enraged client, should be taken very seriously, as these opportunities do not always occur in emotionally charged situations. Many clients are comforted by a sincere apology and an action plan to prevent future errors.

We will also not spend time commenting on whether or not the medical error did in fact cause the pet’s death. Whether the error caused the pet’s death or not, the error occurred, and our focus will be on finding the root cause for the error, and development of an action plan to prevent similar errors in the future.

Root Cause Analysis:

  1. Define the problem
    1. a. What do you see happening?
      A mislabeled/incorrect medication was dispensed to the owner. The error was not realized when the owner brought it to the staffs’ attention. A patient died from clinical signs that may or may not have been a result of the incorrectly dispensed medication.
    2. Are there specific symptoms?
      The patient died severely dehydrated and in renal failure.
  2. Data Collection
    1. Everyone must understand the problem, before it can be analyzed.
    2. Include everyone that can add information from the front desk to clinicians to help gain a better understanding of the problem.
      Attending veterinarian, CVT, reception staff, personal manager/office manager.
  3. Identify or chart causal factors
    1. What order of events leads to the primary problem?
      1. Prescription refill is requested.
      2. Refill is approved by DVM.
      3. Prescription is filled by CVT.
      4. Prescription is sent to the front desk for owner contact, pick up, and payment.
      5. Owner contacts hospital noting that the tablets appear different than previous prescriptions.
      6. Technician advises owner that pills can appear differently with different suppliers.
      7. Pet passes away 3 days after owner begins giving the medications, from severely dehydration and renal failure.
      8. Attending veterinarian realizes that the bottle with label for 5mg benazepril tablets was filled willed 20mg furosemide tablets.
    2. What conditions allow the problem to occur?
      Remember to employ the “5 Whys” when identifying causal factors, and that there may be more than one causal factor.

Patient passed away

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WHY?

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Dehydration, renal failure. The pet was receiving a mislabeled medication. This medication was a diuretic.

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WHY?

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The technician did not verify the prescription was correct when the owner called with questions as to why the pills looked different when compared to previous refills, and assured the owner that the medication was correct.

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WHY?

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The technician reported it was common for pills shapes and sizes to vary with different suppliers of medication. Concurrently, the technician may not have remembered what the pill currently looked like.

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WHY?

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The technician was very busy filling multiple prescriptions and did not take time to check for a change in the appearance of the pill as they may look different if obtained from a different supplier.

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WHY?

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The technician was not adequately trained on the dangers of incorrect administration of medications and no verification protocols were in place for this practice.

4. Root Cause Identification – the identification of the underlying reason or reasons for each causal factor.

  • Why does the causal factor exist?
    In the absence of training, checklists, and protocols to prevent errors, it is very easy to allow assumptions and errors of complacency to occur, especially when there are factors like case load, and human factors contributing to the chaos that is so common in a private practice veterinary clinic.
  • What is the real reason the problem occurred?
    No formal protocol or checklist for filling prescriptions or prescription refill requests.
    No formal protocol for fielding client questions regarding prescription or refills.
    Staff training and documentation of this training is needed

5. Generate and Implement Solutions

  • A formal presentation on this case will be presented to all staff and doctors at a mandatory staff meeting. An important factor in the preventing human errors is sharing and analyzing the experience. The discussion will focus on the proper steps for fielding and documenting client communications and questions over the phone.
  • A formal checklist will be created for the technical staff filling medications, and verifying the accuracy of medications filled. The medical director will formulate this checklist using some of the safe guards that are used in human pharmacies to prevent medication filling errors.

Conclusion:

Did the error in medication dispensing cause the pet’s death in this case? Maybe, maybe not. Remember the focus here is not what caused the pet’s death, but what caused the medical error. The focus of this course is why the error occurred and preventing further errors, not whether or not the error caused the pet’s death. It is however worth noting that in the field of veterinary medicine “perception is reality” for most of our clients. Meaning, in the client’s mind it really doesn’t matter whether the medication error truly caused the pet’s death or not. The client will perceive the medication error as the cause of their pet’s death regardless, as will many of the people and internet followers that the client may share the story with. The fact of the matter remains that a medication was dispensed incorrectly for a pet with a chronic illness.

The Root Cause Analysis has helped us identify the reasons why the error occurred, and this can now be used to help the clinic move forward and prevent similar errors from occurring again. This case illustrates the importance of training, checklists, and protocols. With appropriate training, checklists, and protocols, staff and doctors will use their training even during times of stress and chaos. Without ongoing training, checklists, and protocols times of stress and chaos will produce mistakes. The formal presentation regarding the protocol for handling filling of new prescriptions and refills of existing prescriptions will cover checklists and safety procedures that should be followed EVERY TIME a medication is dispensed. Training and review of these protocols and checklists for dispensing medications will cement them into the minds of staff and doctors, so that even during times of stress the steps will be followed. Similarly, handling and documentation of client phone calls is an excellent opportunity to role play with the staff on how to talk to clients, ask questions, follow through during chaotic times at the clinic, and EMPHASIZE the importance of documenting even the most seemingly insignificant phone calls. For example, had the initial phone calls from this client been documented, another technician, or the attending veterinarian may have seen them and followed up with the owner sooner regarding the medication questions. Furthermore, attending veterinarians can use documented phone calls as learning points and teaching tools with their staff. There is no one right answer in these multi-factorial problems, so regardless of the conclusions that you draw with your RCA, the most important part is to come up with a plan, follow through with the plan, and thoroughly communicate and train for this plan with everyone involved.

Back to: Medical Errors and Prevention Techniques in Veterinary Medicine – Texas

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