Vet med grad student's project turns medication near-misses into action

Faculty of Veterinary Medicine PhD student Renata Pinho, DVM, didn’t set out to get into marketing. But when her grad project on peri-anesthetic (before, during or after anesthesia) errors and safety caught numerous errors, she knew action needed to be taken.

“Peri-anesthetic errors are known to occur in humans, but in veterinary medicine, it is largely unstudied,” Pinho explains. “We initially focused on errors relating to medications and were expecting to see calculation errors in medication delivery, which we do see in humans, but we weren’t expecting to see issues with look-alikes.”

‘Look-alikes’ are medications with similar names or packaging that could be mistaken for one another. Ephedrine and epinephrine are a common example of this.

Ephedrine, a central nervous system stimulant, is used to treat low blood pressure during anesthesia. Epinephrine, primarily used for treating cardiac arrest and severe allergic reactions, is a much stronger medication. Not exactly the kind of medication you want to be mixing up.

“In human medicine, around one in 20 medication administrations during the peri-anesthetic period is associated with an error. However, the majority of these are near-misses,” explains Pinho’s supervisor Dr. Daniel Pang, BVSc, MSc, PhD.

“A near-miss doesn’t ‘hit’ the patient — it is caught in advance through a system of robust procedures and protocols to catch anything that could slip through or sometimes, just through good luck. Adverse events are what hit patients, and fortunately, those are rare.”

By partnering with the Institute for Safe Medication Practices (ISMP) Canada, which specializes in analyzing reports of medication errors from practitioners of human health across the country, Pinho was able to collect data from half a dozen veterinary clinics that participate in University of Calgary Faculty of Veterinary Medicine’s (UCVM) distributed veterinary learning community (DVLC).

The ISMP system is self-reported and offers the benefits of confidentiality and anonymity. Despite movement over the past 20 years to decrease the stigma surrounding near-misses, there is still trepidation when it comes to reporting mistakes.

Understandably so. “Veterinarians and veterinary technicians hold themselves to very high standards and find it hard to discuss mistakes. Creating a safety culture, where mistakes are recognized and learned from, is an ongoing process,” Pang explains.

But not to worry. The good news is that by studying near-misses, where harm to patients does not occur, we can learn a lot about how to make our systems and procedures stronger. This could include building a veterinary database for collecting and analyzing errors, with researchers like Pinho and Pang devoted to understanding and reducing error rates.

Companies are also watching this. Along with traditional funders such as Alberta Graduate Excellence Scholarship and Association of Veterinary Anaesthetists Educational Trust Fund, the Zoetis Investment in Innovation Fund was the major sponsor of Pinho’s research.

Pinho explains corportate action taken because of her research: “Dexmedesed (dexmedetomidine) came in a blue bottle that was very similar to Comfortan (methadone) that also came in a blue bottle. As both medications are frequently used during the peri-anesthetic period, but have very different doses and effects, the consequences of mixing them up are potentially serious. As look-alike medications, it is not unheard of that a veterinarian or technician could reach for the incorrect bottle.”

Upon learning of these findings, the maker of Dexmedesed has taken the initiative to repackage their medication to add another layer of safety in the clinical setting.

This is a small win in a future with potential for countless others. Pinho isn’t stopping here. “After my PhD, I plan to continue performing clinical work on veterinary anesthesia. I intend to continue studying and investigating patient safety and strategies to mitigate errors,” says Pinho.

“My focus is on sharing information and improving education for a safety culture in veterinary anesthesia.”