A medication error, as defined by the National Coordinating Council for Medication Error Reporting and Prevention, is “any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient, or consumer. Such events may be related to professional practice, healthcare products, procedures, and systems, including prescribing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use.”1
Medication errors are a common cause of complaints in veterinary practice, and yet most of these mistakes can be prevented by having checks and balances in place to minimize the risk. One way veterinary teams can help prevent medication errors is by familiarizing themselves with (and periodically reviewing) drug inserts. No matter how common a drug is or how often it is used in practice, this important habit serves to remind veterinary teams of drug interactions, precautionary information, patient monitoring recommendations, and adverse reactions. Additionally, if a medication is used in an off-label manner, the risks must be reviewed by the treating veterinarian, and client consent must be obtained. The following closed claims demonstrate the importance of practicing good medicine.
Medication Error Closed Claims
Adverse Drug Interaction Results in High Payout
Dr. A was presented with a 10-month-old Thoroughbred filly for right forelimb lameness. Dr. A found moderate soft tissue swelling around the distal cannon bone area and down through the pastern with pitting edema. A sprain was suspected, and Dr. A prescribed antibiotics, flunixin meglumine, omeprazole, and trazodone. Trazodone alone was not effective, so three days later, Dr. A administered reserpine to the filly after consulting with the farm manager. The trazodone treatment was also continued.
The filly reportedly began to show neurological signs the following day. Eighteen days later, the filly was unable to stand from sternal recumbency. A presumptive diagnosis of serotonin syndrome was made, and the filly was euthanized due to a poor prognosis. The filly’s owner demanded reimbursement for its value and alleged negligence, and Dr. A submitted an insurance claim with their professional liability carrier. After an internal review, it was concluded that the off-label administration of reserpine necessitates caution when used in conjunction with additional sedatives or anesthetic agents within a there- to four-week period post-administration. The concurrent use of trazadone and reserpine likely resulted in the serotonin syndrome. The insurance carrier negotiated a $300,000 settlement, and Dr. A consented to settle.
Mislabeled Medication Leads to Positive Drug Test
A 5-year-old Thoroughbred mare with a history of exertional rhabdomyolysis presented to Dr. B for a pre-race consultation. Dr. B prescribed two tubes of Lactanase paste to help treat the muscle condition. (Lactanase is the brand name for a vitamin supplement that works to support muscle function and improve muscle recovery after exercise.) Dr. B administered one of the tubes to the horse the following day, three days prior to race day. The mare won the race, which was a stakes race, but tested positive for dexamethasone and was disqualified. All purse money was returned.
An investigation as to the possible cause of the positive drug test revealed that the Lactanase paste dispensed by Dr. B was a mislabeled tube of Naquasone paste (trichlormethiazide and dexamethasone drug combination). The investigation revealed that the tube of Lactanase had been properly labeled by the manufacturer, but Dr. B had made a labeling error. The client requested that Dr. B reimburse them for the purse money, and Dr. B reported the incident to their professional liability carrier. Due to the medication mixup, Dr. B consented to settle, and the insurance company negotiated a settlement for $90,000.
Patient Monitoring Mishap Results in Irreversible Renal Failure
A 6-month-old Quarter Horse filly presented on emergency to Dr. C’s facility after becoming entangled in a fence and suffering severe limb lacerations. Surgery was performed to treat and suture the lacerations, and Dr. C placed the filly on a treatment plan that included the antibiotics ceftiofur (IM), gentamicin (IV), and flunixin meglumine (IV). Due to the high risk of infection, the filly’s owner elected to continue hospitalization so that the IV injections could be given appropriately. Over the course of treatment, the filly received the medications, as well as wound care and bandage changes.
After several days of hospitalization, the filly’s appetite declined, although it remained alert, active, and still eating other types of feed. Dr. C ordered a chemistry panel, which revealed significantly elevated renal values. Acute kidney injury was diagnosed, and Dr. C suspected drug-induced nephrotoxicity, likely from the gentamicin and flunixin meglumine. The owner was informed of the situation, the medications were discontinued, and IV fluid diuresis was attempted, but the filly did not respond to treatment and was referred to a specialty clinic.
The filly’s condition continued to decline, and euthanasia was elected. The owner sought reimbursement for damages, the filly’s value, and medical costs from Dr. C. After Dr. C alerted their insurance carrier, an investigation into the case determined that there were concerns that the combination of the aminoglycoside antibiotic and the NSAID caused the acute renal injury, and that the injury may have been prevented through closer monitoring of the patient’s blood work, adjusting drugs and or dosages, and ensuring that the filly was well hydrated. Dr. C agreed to move forward with settling the matter, and the insurance carrier negotiated a settlement for $43,000.
Reference
- “Veterinary Medication Errors,” U.S. Food and Drug Administration, https://www.fda.gov/animal-veterinary/product-safety-information/veterinary-medication-errors
Related Reading
- The Business of Practice: Avoiding Veterinary Medical Record Errors
- Responding to Client Complaints and Avoiding Malpractice in Equine Practice
- Update Your Equine Clinic to Reduce Medical Errors
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