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Part One
Medical and Treatment Errors
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1
Coming Up for Air
When equipment failure can be fatal
Barney had been vomiting for 2 days, but this was not usual. Mr. and Mrs. Thompson explained that Barney vomits about once a day, so they were originally not that worried about the vomiting. When Barney failed to stop vomiting and refused his dinner, they knew it was time to get him checked out. Dr. Crane was working emergency that night, and the clinic had been slow to that point in time. Compared with many 4-year-old domestic shorthair cats that Dr. Crane had seen, Barney was clearly overweight but his vital signs were normal. Barney was a bit quiet and somewhat dehydrated, and Dr. Crane suspected that Barney’s abdomen was a bit uncomfortable; however, no clear abnormalities were noted on abdominal palpation. If not for the complete oral exam, Dr. Crane might not have found the string trapped under the base of the tongue.
A presurgical workup was quickly completed, and Barney was given intravenous fluids and antibiotics. Plication of the small intestines was suspected based on abdominal radiograph, and Dr. Murray was called in to perform the surgery so Dr. Crane could continue to manage the evening’s slowly increasing emergency caseload. Anesthesia induction was smooth, Dr. Murray quickly found the plicated region of the small intestinal track, and the entire string was removed with only three enterotomies. Surgery was completed without any complications, and Barney was returned to the intensive care unit for anesthesia recovery and ongoing care. Postoperative point-of-care testing identified mild hypokalemia, and Barney was still mildly dehydrated so intravenous fluids were prescribed. Louise, the technician working at the emergency clinic that night, was busy with other cases, so Dr. Murray added potassium to the fluids, labeled the bag, then inserted the fluid administration set. When Louise was free to help, Dr. Murray left to telephone Mr. and Mrs. Thompson with the surgical findings and the postsurgical plans, including the recommendation that Barney stay a night or two for ongoing supportive care.
The technician started the fluids, and a few minutes later, Barney collapsed, stopped breathing, and had no pulse. Cardiopulmonary resuscitation (CPR) was initiated, and Barney was immediately intubated and external cardiac compressions were begun; CPR was continued for 15 minutes until bloody edema fluid was seen pouring from the endotracheal tube without any evidence of any response to CPR.
Resuscitative efforts were unsuccessful, and Dr. Murray returned to the phone to advise the Thompsons of the catastrophic development. The Thompsons could not understand how Barney could have survived the surgery, and how they could have been given such an optimistic postoperative update, only to be called 15 minutes later with notification of Barney’s death.
The individuals involved reviewed the case to determine what might have happened. Iatrogenic hyperkalemia was entertained as a possibility, but Dr. Murray was certain she had added the correct amount of potassium to the fluid bag. Neither Dr. Murray nor Louise could recall purging the intravenous fluid line of air, and this was a point in transfer of care between two individuals on the health-delivery team. Heart disease was considered as a possible complicating factor because of the bloody fluid noted from the endotracheal tube; however, no cardiac abnormalities had been noted on exam, there were no abnormalities on the electrocardiogram during anesthesia monitoring, and Barney was not short of breath just prior to the cardiopulmonary arrest. It was suspected that the intravenous fluid line had not been purged of air prior to the infusion pump being started and the cat had therefore received an intravenous air bolus of approximately 15–18 mL. A postmortem thoracic radiograph confirmed air in the right atrium.
The Thompsons called the next day and filed a complaint with the hospital director. After meeting with the director and Dr. Murray, the Thompsons had a better understanding about the events and, although they had lost their pet, they appreciated the full disclosure, honesty, and obvious remorse shown by Dr. Murray during this face-to-face conversation.
Key Points
- The diagnosis was not delayed, in part due to Dr. Crane’s thorough examination. If the string under the tongue had been missed, diagnosis might have been delayed and peritonitis could have been a complicating outcome.
- In this case, a simple technical error cost Barney’s life. This highlights the recommendations of having a simple procedural check-off, such as all fluid sets being checked for air by the person connecting them to the patient, especially due to the more widespread use of fluid pumps. The point in time where there is a transfer of duties from one individual to another is a key situation where mistakes are especially likely to happen; communication between team members regarding what has been done and what still needs to be done is essential.
- Catastrophic and unexpected developments are difficult for most clients to accept, especially when such events are in direct contrast to a recent communication. Clinicians have individual preferences in how to approach these situations, but honesty about the events is always best. Some clinicians start the conversation with “I have some very sad news about Barney,” while others might approach it with a longer version culminating with the loss of Barney. The trajectory of the conversation will vary from case to case, but most owners want to hear specific information about what transpired just prior to and at the time of the crisis. In many cases, the unexpected nature of the event and the grief associated with loss of the pet means that the subject of charges for care is best avoided in this first conversation, unless it is brought up by the owner. Some owners need time to accept this information, and a subsequent conversation is required to determine disposition of the body, whether or not to perform a necropsy, and other details. Financial decisions should be made by the hospital owner or practice manager, in consultation with their liability insurance carrier.
- Meeting personally with all parties involved allowed this case to be resolved in a professional manner, and it allowed the Thompsons to fully express their concerns. In addition, Dr. Murray was able to explain the situation and express his true remorse about the outcome. In this case, the Thompsons were not charged for any of the hospital services, and they left knowing that the doctors and administrators truly cared for their cat and were very sorry about what had transpired.
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2
Alistair and the UTI
Sometimes antibiotics ARE indicated!
Alistair was a giant ginger-and-white cat. He had been previously healthy, but last night was in and out of the litter box and this morning his owner (Ms. Bristol) found him collapsed on the floor. Alistair was rushed to the veterinarian and was found to have a urethral obstruction. The obstruction was easily relieved, but Dr. Patrick decided to keep him in the hospital for a few days until he had completely recovered. It had been relatively hard to pass the original catheter, and Dr. Patrick wanted to make sure he would not reblock. The routine laboratory work was normal; a urinalysis showed no evidence of infection, but there was a high pH and many struvite crystals.
After 2 days, Alistair seemed to be well recovered, the urinary catheter was removed, and the plan was to discharge him later that same day. He was treated with only intravenous fluids and no antibiotics; Dr. Patrick was careful to always explain to clients that a urinary infection and urethral blockage were very different and that cats with urethral blockage rarely, if ever, had an associated infection.
However, as the day wore on, it was clear that Alistair was not totally fixed. He was straining a lot and by 4 P.M. he had not produced a drop of urine. His bladder was lemon sized. Dr Patrick recatheterized Alistair and elected to keep him in the hospital another few days. The urine looked a bit cloudy, which Dr. Patrick attributed to inflammation.
Two days later, the catheter was pulled again and Alistair was discharged home on canned food (Hills C/D) and prazosin (a medication to help decrease urethral spasm), with instructions to carefully monitor his urinations. Ms. Bristol listened carefully to the directions, but because she had already spent a lot this week on Alistair, she decided to not to tell Dr. Patrick that she was going to out of town for 36 hours and Alistair was going to be on his own.
When Ms. Bristol returned from her trip, she found Alistair collapsed, in a puddle of urine. He was immediately brought back to the hospital. On examination, he was hypothermic, was icteric, was painful in the abdomen, and had a strong smell to him. Laboratory testing documented 2000 white blood cells with 1000 bands (a degenerative left shift). A chemistry profile was supportive of mild azotemia (creatinine 1.9 mg/dL) and an elevated bilirubin value. A urinalysis showed “too numerous to count” white blood cells and 4 + rods, and a urine culture ultimately identified a sensitive Escherichia coli. Alistair was treated aggressively for urosepsis and, after 7 days in the hospital, made a full recovery.
Key Points
- As believed by Dr. Patrick, the feline lower urinary disease or obstruction is typically sterile, and careful antibiotic selection is advisable to prevent multi-drug-resistant organisms from developing.
- Alistair developed a severe urinary tract infection (UTI). The most likely scenario is that, although the urine was initially sterile, the first somewhat difficult catheterization had resulted in colonization of the bladder. In most cats, the urinary system will rapidly clear itself of organisms; however, in this case, when Alistair reobstructed, there was ample time for infection to develop.
- Dr. Patrick should have more closely evaluated the urine when it was noted to be cloudy; infection was already present at this point, and earlier treatment might have limited the development of overwhelming sepsis.
- While not clearly his responsibility, Dr. Patrick ideally should have confirmed with Ms. Bristol that she would be home for the weekend and would be able to care for Alistair.
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3
Double-Check the RX
How a simple math error cost a dog his life
A 15-month-old, male intact Akita named Dakota was presented to an emergency doctor for an acute onset of respiratory distress and with severe lethargy. He had a history of having prednisone- responsive weakness and collapsing episodes for several months. When the episodes increased with decreasing dosages of prednisone, he was scheduled to be referred to an internist for further diagnostic tests. Due to his acute signs of disease, he was evaluated through the emergency service, then hospitalized and transferred to internal medicine for therapy and diagnostic testing. In addition to the collapsing episodes, Dakota was having intermittent difficulty prehending food.
On admission, his body temperature was 103.7°F (39.8°C), his heart rate (HR) was 156 beats per minute (bpm), and he was panting. His mucous membranes were mildly cyanotic. No murmur or arrhythmia was auscultated, and his peripheral pulse quality was weak. Increased lung sounds were auscultated in all lung fields. Neurologic examination revealed normal cranial nerve function and no conscious proprioceptive deficits. The next morning, he was fully and strongly ambulatory, but 6 hours later he was found to have difficulty walking, with significant hindlimb weakness. He had a mild amount of muscle wasting in his head and thigh regions.
Thoracic radiographs showed a megaesophagus, along with an interstitial to alveolar pulmonary infiltrate in the left cranial, right cranial, and right middle lung lobes. A pulse oximetry reading on presentation was 86% on room air. A transtracheal wash was performed, and cytology was consistent with septic, neutrophilic inflammation in the lungs.
Because of his historical clinical signs and diagnostic findings, myasthenia gravis was suspected. To confirm this diagnosis, a tensilon test was performed. He was administered 2 mL atropine intramuscularly, followed by 5.8 mg of edrophonium (tensilon) intravenously. Following tensilon administration, Dakota immediately rose and strongly ambulated around the exercise yard for 2 minutes, before becoming weak again. The test, therefore, was considered a strong positive for a diagnosis of myasthenia gravis. Definitive diagnosis of myasthenia gravis is based on results of an antiacetylcholine receptor antibody test, performed on patient serum, with results available in 10–14 days.
Neostigmine was prescribed as a therapy for the myasthenia gravis. Neostigmine is a parasympathomimetic that helps myasthenic patients by competing with acetylcholine for acetylcholinesterase, therefore allowing prolongation of acetylcholine effects at parasympathetic receptor sites. The dose Dakota was supposed to receive was 1.5 mg as an intramuscular injection. However, he accidentally received 15 mg, 10 times the appropriate dose. An overdose of neostigmine can cause a cholinergic crisis, exhibited as nausea, vomiting, diarrhea, excessive salivation, miosis, lacrimation, increased bronchial secretions, bronchospasm, bradycardia, hypotension, muscle weakness, restlessness, and agitation.
Ten minutes after receiving the neostigmine, Dakota immediately rose, ate some food, then began vomiting profusely, and seizured. At this time, the medication error was recognized, and atropine was administered as an antidote, following a dose of valium to treat the seizure. Dakota then became severely cyanotic with accompanying significant respiratory distress. Severe bronchoconstriction was suspected. He was then treated with terbutaline subcutaneously and inhaled albuterol. When these treatments did not improve his respiratory status, he was administered epinephrine subcutaneously. It was then decided to sedate, intubate, and place Dakota on a mechanical ventilator for respiratory support. When intubating, food particles were noted within the tracheal lumen, indicating aspiration.
Dakota was placed on a ventilator and treatment for bronchoconstriction continued. The effects of neostigmine last about 4 hours in humans, when given parenterally. Despite aggressive respiratory support, Dakota experienced cardiopulmonary arrest 13 hours after receiving the overdose of neostigmine. Resuscitative efforts failed.
Key Points
- Administering an inappropriate dose of medication can have disastrous effects. An estimated 770,000 people are injured or die each year in US hospitals from adverse drug events (ADEs), defined as an injury resulting from medical intervention related to a drug.1 Many of these adverse drug events are preventable. Incidence of ADEs is not available for veterinary patients; however, medication errors are known to occur, potentially resulting in some degree of morbidity and, as in Dakota’s case, mortality.
- Client communication and incidence reporting are necessary and ethical when medication errors occur. Mistakes do occur, and by being honest and straightforward about the incident, many owners are more understanding and, although they may be angry, realize that it was an accident that is currently being addressed. Dakota’s owners were immediately contacted and informed of the mistake made by the hospital. Because it is not a medication that is used very often, the excessive volume administered did not bring about alarm. The attending veterinarian continued to stay in very close contact with the owner throughout the day and into the night. Although the outcome was fatal, because the owners were kept informed of the full clinical course and details about Dakota’s case, they were more forgiving in the end. The owners of Dakota were not responsible for the final bill of $4200.
- Before administering any medication, the dose should be calculated and checked by another person, especially if it is a drug that is not used regularly.
- Mistakes occur, and open communication with the owners is paramount to the success of the case and in future contacts with the clients.
- Good faith compensation, open communication, and honesty about the error help to maintain a solid reputation and may prevent future litigation.
Reference
1. Agency for Healthcare Research and Quality. Reducing and preventing adverse drug events to decrease hospital costs. Research in action, Issue #1, March 2001. [Available via www.ahrg.gov/aderia/aderia.htm (accessed April 2010).]
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4
Holey Chest Tube!
How some inadvertent complications led to a change in standard operating procedure
Bruno, a 4-year-old neutered male Husky, presented to the emergency service with a history of acute respiratory distress. He had no history of trauma and was closely supervised at all times. He had no history of prior medical, surgical, or traumatic disease.
On physical examination, Bruno was distressed, tachypneic, and orthopneic. His mucous membranes had a grayish- muddy discoloration. The capillary refill time was normal. His heart rate was 160 beats per minute, with an auscultatable regular rhythm and moderate femoral pulse quality. Lung sounds were bilaterally muffled in all fields, especially dorsally. Abdominal palpation was unremarkable; he was fully ambulatory, with no evidence of gross traumatic injury.
Pulse oximetry readings were between 88% and 90% on room air, improving to 92% with oxygen flow-by. Emergent thoracic radiographs revealed a severe pneumothorax. Thoracocentesis yielded 1200 mL of air from the left hemithorax and 800 mL of air from the right hemithorax. The patient stabilized following thoracocentesis and was admitted to the intensive care unit.
Blood work, including a complete blood cell count and serum chemistry profile, was within normal limits. An arterial blood gas was performed following thoracocentesis and yielded a normal acid-base status, a partial pressure of oxygen (PaO2) of 95 mmHg, and an oxygen saturation of 97%.
Two hours after initial presentation, Bruno became tachypneic again, with increased respiratory effort. Blood oxygen saturation at that time was 88%, as measured by pulse oximetry. Dull lung sounds were noted bilaterally, and thoracocentesis was performed once more. At this time, no endpoint to the air production could be obtained, and thoracostomy tube placement was recommended.
Bruno was placed under general anesthesia, with propofol induction and maintenance on inhaled isofluorane. A thoracostomy tube was placed by making a small skin incision, then forcing the tube into the pleural cavity by direct pressure. The chest tube entered the pleural cavity, and continuous air was obtained. Postplacement thoracic radiographs showed proper placement of the tube, and a mild pneumothorax. The tube was then attached to a continuous pleural suctioning unit (Pleurovac®) in the intensive care unit. Recovery from anesthesia was uneventful.
Significant amounts of air were produced from the chest tube over the next 48 hours. At this time, because the primary differential diagnosis was a spontaneous pneumothorax due to underlying pulmonary bullae, exploratory thoracotomy was performed.
During surgery, the previously placed thoracostomy tube was found to be impaling one of the lung lobes (see Figure 4.1). No other areas of air leakage were noted. A partial lung lobectomy was performed, and another thoracostomy tube was placed surgically, for postoperative monitoring. No air production occurred over the next 24 hours, and the chest tube was removed.
Bruno was discharged from the hospital the following day. He has had no further problems att...
