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To Err is Human

Most healthcare workers, human and veterinary, have witnessed or been a part of a medication error. A 2012 human study estimated that every year in the U.S. preventable injectable medication adverse events impact 1.2 million people. 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 emergency and specialty centers, I have sadly seen a lot of veterinary medication errors. Similar to human studies, most have caused no harm. I’ve seen patients get an antibiotic twice when nurses were trying to help each other and forgot to sign the treatment sheet. I’ve seen a dog get an opioid overdose when a doctor made a 10x math error but it was caught quickly and reversed.

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

In an even sadder case, a cat came in for severe weakness. He was found to have a low red blood cell count that was related to his bone marrow not working. 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).

Cornell’s College of Veterinary Medicine implemented a system of voluntary reporting of all medical errors several years ago. The goal was to understand why errors occurred to develop systems for prevention. They recently published what they learned from three years of reporting. They found that their incidence of errors was 5 per 1000 patient visits. Medication errors were the most common type.

Why do Medication Errors Happen?

It is easy to blame 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 emergency hospitals, 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.”

Types of Medication Errors

As shown in the examples above, medication errors can happen at different steps in the prescribing and administration process. We teach the six rights of medications to help our staff remember and double check all of the steps. The six rights are:

• Right patient
• Right medication
• Right dose
• Right route
• Right timing
• Right documentation

Patients and Clients can Help Prevent Errors

Human medicine has acknowledged that patient and family involvement can make medicine safer. In the past, people were often not kept in the loop and questions were not encouraged. Many physicians have now realized that patients and their families can help prevent mistakes. The Institute of Healthcare improvement has created a framework for safe, reliable and effective care that puts patients and families at its core.

Ten Medication Error Prevention Steps

What can you as a pet owner do to prevent a medication error with your pet?

1) Never give your pet an over-the-counter medication without checking with your veterinarian. A single adult Tylenol tablet can kill a cat. Ibuprofen is quite toxic to both dogs and cats.

2) ALWAYS check new and refill prescriptions for your pet’s name before you take it home and administer. While there are no studies in veterinary medicine, the Institute for Safe Medication Practice found that one out of every 1000 prescriptions filled has the wrong person’s medication in the bag.

3) Understand WHY you are giving each medication and any side effects. It is important to understand what each medication does, why you are giving it, and if there are any significant risks or major side effects. If you then see a problem, you’ll know to stop the medication until you can reach your veterinarian.  

4) Ask about medication interactions. If your pet is taking multiple medications, it is important to make sure your veterinarian has a complete list of what your pet is taking and for you to ask if there are any possible interactions if a new medication is added. For example, steroids and non-steroidal anti-inflammatory medications should NEVER be given at the same time. In addition, giving multiple pain medications can sometimes cause your pet to be overly sedate. Remember that herbal medications and supplements as well as products bought online or at a pet store count as medications.

5) ASK for a staff member to go over the medication instructions with you before you leave the hospital. By having a staff member look at the bottle with you, to explain the label instructions and how much to give, you can avoid a misunderstanding over dose, route, or timing. Ask about missing a dose; in most cases, it’s best not to double up if the next dose is imminent, but ask what you should do.

6) When giving a liquid medication, make sure you understand the dosing amount. Early in my career, I asked a client to administer 2 ml (two milliliters) of an antibiotic twice daily. I gave her a 3 ml syringe. I did not mark on the syringe and she ended up giving 0.2 ml (only 1/10th the dose). I now always mark the exact stop on the syringe and show the client. It is important to double check with your vet on this.

7) When picking up a pet medication at a human pharmacy, make sure you have the name and dose of what you are getting. Errors can occur either when written prescriptions are faxed or when prescriptions are called in over the phone. Knowing both the medication name and what the medication does can help prevent having the wrong medication dispensed. Also check refill medications for errors.

8) Keep medication up high and out of reach of pets and children. Carprofen, a commonly administered pain medication for dogs, comes as a chewable tablet. They were made to taste good so they would be easy to administer. Unfortunately, they taste so good that I have treated multiple dogs for toxicity that have eaten their entire prescription and the bottle at one sitting! These medications need to be kept in cabinets, not just on the counter.

9) Store pet medication AWAY from your medication. I have seen people take their pet’s medication by accident AND I’ve had owners give their own medication to their pets. This has risks for both you and your pet. The best way to prevent this type of mistake is to store these medications in SEPARATE spots.

10) Bring a list of your pet’s medications if you go to a new veterinarian or emergency hospital. Medication errors become more likely if there are multiple hospitals or multiple doctors involved. It is important to let any new veterinarian know ALL current medications and supplements your pet takes.

Following these ten steps will help avoid a medication error for your pet and are also recommended for your own medication safety. The FDA also has further information on preventing medication errors. 

Beth Davidow, DVM DACVECC is a consultant for VIN and also blogs as The Veterinary Idealist on issues of ownership, quality, community and sustainability