A profile of morbidity and mortality rounds within resident training programs of the American College of Veterinary Surgeons

Accidental intraarterial propofol injection in a dog

Medication errors are the most common type of medical error in veterinary medicine, with drug delivery by the wrong route comprising 8% of medication errors. A healthy, 4-year-old, 13 kg, mixed breed female dog was admitted for elbow surgery. After premedication (dexmedetomidine 0.5 μg kg-1, methadone 0.3 mg kg-1 and alfaxalone 0.5 mg kg-1 intramuscularly), general anaesthesia was induced with alfaxalone (1 mg kg-1) injected intravenously through a catheter placed in the right saphenous vein. Anaesthesia was maintained with isoflurane in oxygen. Physiological monitoring comprised electrocardiography, noninvasive arterial blood pressure, capnography and pulse oximetry. A catheter was placed in the left dorsal metatarsal artery for planned arterial blood pressure monitoring intraoperatively and an injection port attached. While waiting for transfer to surgery, anaesthesia was monitored by a student. When the dog spontaneously moved, the student was unsure what to do and the supervising anaesthetist injected propofol (1 mg kg-1) into an injection port, believing it to be attached to an intravenous catheter. Depth of anaesthesia was corrected. Thirty minutes later, white fluid was noticed in the hub of the intraarterial (IA) catheter when the injection port was removed to connect the extension line, prompting a realization that propofol had been injected IA. Physiological variables, the IA catheter and the anaesthetic record were examined. A slight reduction in HR was the only change following IA propofol injection. No further complications occurred. Following investigation, four potential factors contributing to the medication error were identified: 1) individual - distraction; 2) surgical procedure - unusual intravenous catheter location; 3) organization - shortage of appropriately trained personnel to monitor anaesthesia due to miscommunication between anaesthesia and surgery services; and 4) organization - standard practice to not label IA catheters until the postoperative period. Mandatory IA catheter labelling immediately after placement and improved interdisciplinary communication were implemented at the institution.

Ethical Challenges Posed by Advanced Veterinary Care in Companion Animal Veterinary Practice

Simple Summary

Veterinary care of companion animals, particularly dogs and cats, continues to advance, with some companion animals receiving a standard of care equal to or exceeding that of human patients. While this has the potential to improve animal welfare and benefit other stakeholders, including animal owners and veterinary team members, it also poses ethical challenges. We discuss key ethical challenges associated with AVC, including its relationship to standards of veterinary care, its potential to perpetuate poor quality of life and suffering, cost and accessibility of veterinary care, conflicts of interest, and concerns about experimentation without appropriate ethical review. We conclude by suggesting some strategies for veterinary teams and other stakeholders, such as professional bodies and regulators, to address these concerns.

Abstract

Advanced veterinary care (AVC) of companion animals may yield improved clinical outcomes, improved animal welfare, improved satisfaction of veterinary clients, improved satisfaction of veterinary team members, and increased practice profitability. However, it also raises ethical challenges. Yet, what counts as AVC is difficult to pinpoint due to continuing advancements. We discuss some of the challenges in defining advanced veterinary care (AVC), particularly in relation to a standard of care (SOC). We then review key ethical challenges associated with AVC that have been identified in the veterinary ethics literature, including poor quality of life, dysthanasia and caregiver burden, financial cost and accessibility of veterinary care, conflicts of interest, and the absence of ethical review for some patients undergoing AVC. We suggest some strategies to address these concerns, including prospective ethical review utilising ethical frameworks and decision-making tools, the setting of humane end points, the role of regulatory bodies in limiting acceptable procedures, and the normalisation of quality-of-life scoring. We also suggest a role for retrospective ethical review in the form of ethics rounds and clinical auditing. Our discussion reenforces the need for a spectrum of veterinary care for companion animals.

Morbidity and Mortality Conferences: A Mini Review and Illustrated Application in Veterinary Medicine

This mini review presents current knowledge on the role of morbidity and mortality conferences (M&MCs) as a powerful educational tool and driver to improve patient care. Although M&MCs have existed since the early twentieth century, formal evaluation of their impact on education and patient care is relatively recent. Over time, M&MCs have evolved from single discipline discussions with a tendency to focus on individual errors and assign blame, to multidisciplinary, standardized presentations incorporating error analysis techniques, and educational theory. Current evidence shows that M&MCs can provide a valuable educational experience and have the potential to generate measurable improvements in patient care.