clinical mistakes

A few years ago we were drawing blood from a very ancient, very dehydrated cat with suspected kidney failure and as the other tech went to draw from the jugular vein we noticed there was a huge wound next to it. It was as though the skin had opened up vertically along the side of the vein. We called a doctor to come look at it and then noticed 2 more wounds on the back of the neck that looked similar to the first one. That's when we realized we had caused these by simply holding him. His skin was so fragile and the doctors thought the toxins from the kidney failure contributed to his skin literally breaking apart, but we still felt absolutely awful. The owner chose to euthanize when we showed him what was happening and after he was dead we examined his skin and found that any amount of slight pulling or pushing caused his skin to split apart.

It's natural to feel awful if you think you caused harm to an animal and I wish I had better words of advice that would make it less painful. The only thing that helps me is thinking it's better to try and help them and risk a negative outcome than to avoid helping at all and guarantee one.

A doctor I work with remembers an instance during her fourth year where her classmate injected potassium into a fluid bag to administer IV to a professor's animal she was in charge of, only she forgot to mix the bag well before hooking it up to the cat. The potassium didn't dissolve properly, floated to the bottom of the bag and overdosed the cat in minutes. As horrible as that was, none of the people involved ever made that mistake again and the people they've told probably won't either.

It's either all the endocrine cramming I've been doing tonight, or the fact that I had a (albeit rare) Cushing's Disease cat ten years ago-- but the skin pulling apart is exactly what my cat had towards the end.
I recall both my frustration and profound sadness at the time. It was a young, rather newly-minted DVM who saw her as an emergency that night and recognized her condition.

An acquaintance of mine was working at a clinic where they needed to insert an NG tube in a young cat. Well, they didn't check the placement before they fed it 60mLs of liquid food. Yep, right down the trachea. That one actually was one of those "feel like you have been kicked in the stomach" when you hear about it cases. The thought still upsets me.

I know a vet that injected drugs into the horses carotid artery instead of jugular vein... horse flipped over backwards seizuring...

I've also seen a horse come into the clinic because the local vet placed oil in its lungs (by passing a nasogastric tube and not checking for placement)... He put 1/2 a gallon in, and a few drops can kill the horse from aspiration pneumonia...

Everyone screws up now and then, some worse than others. Horse A lived, just got a few scratches... Horse B, died. Both bad situations, but the outcome depends on the patient, and the aftercare in some cases.

For me, it was the simplest task I think anyone could have asked - I was helping prep a young dog for surgery, and the vet asked me to shave her stomach. Having watched someone shave dogs a thousand times, I thought it would be no problem. I was very gentle and careful. Pleased when I finished, I went into the other room to get the suds to wash her up. When I came back, lines of red ooze covered her stomach in every direction, and I almost cried when I saw her. I felt horrible and definitely lost a huge amount of confidence in myself for not even being able to properly use an electric razor.

My vet cursed when he saw her, then laughed at me and showed me how to actually hold the razor, etc. We put good "magic healing" cream on her after the surgery was over, and they assured me I wasn't the first to ever botch up a shaving job and that she would be okay. That tender puppy skin is not to be messed with!

Ok, well my story is not a clinical story but more to do with public health but here goes:

We were responding to a rash of dead rodents and lagomorphs in Northwestern part of the state that animal control personnel and ranchers were reporting. We set up a field station and donned our pappers in the case of it being plague or tularemia (pappers = watered down version of spaceman suit). After leaving our traps out for a night and gathering them up the next morning (one complete with a happily fed rattlesnake) we started doing our necropsies in almost 100 degree weather. I was sweating profusely in my suit and hadn't eaten that well that morning and wsa dizzy and not feeling well and during the necropsies, I mislabeled the entire batch, superimposing the labels for the spleen, heart, liver, and lungs. Honestly, nothing was labeled correctly!!! More baffling was that lab personnel at the CDC didn't catch the mistakes until half the batch was tested . . .?????????

Needless to say, half of those tests were deemed unsatisfactory . . . costing our program alot of money . . .I was so embarressed! My boss (a vet) and colleagues had a good laugh and bought me some gag gifts on account of that and my boss tried to make me feel better by saying when she was in clinical practice she had lost a newborn kitten down a drain . . .!!!???? Yeah, that did make me feel better.

The best lesson I ever learned came from a very prominent and well respected faculty member at a US vet school:

"There are two kinds of veterinarian in this world: those who have made an egregious error and those who will someday. I am in the former category."

This came in a private email to my boss, some time before I even started working as a tech. Knowing that someone I will always consider to be my professional idol would say something like this is really scary (because I am pretty sure I will *never* be as good as she is), but also somewhat reassuring. Mistakes will happen. It's how you respond to mistakes that defines you.

I wish I could say that when you get more practice, you won't make any mistakes, but unfortunately that's not true. Everyone makes mistakes, but in our profession it can cost lives which makes it so much harder to deal with. I've heard and seen all kinds of stories as well as making my own where little mistakes can have big consequences. Even well experienced vets. Drug doses, drug interactions, not checking for concurrent disease, etc are all really common mistakes that can have huge consequences. It's good to feel bad about them even if they were completely honest mistakes. You'll still learn from them and improve from them.

If you give the antisedan first the Domitor doesnt work as well.

I've made a bunch of mistakes while working with animals, but luckily none of them have been fatal (at least that I know about). Some being busted veins that bled profusely, dropped baby skunk, etc... I felt really really bad about some of them, but I think I've come to terms with the fact that accidentally harming or even killing animals is sometimes inevitable. As long as you weren't being negligent I don't think you should blame yourself too much.

For example, I knew a vet who was trying to neuter a dog and accidentally dropped the scalpel into his abnominal area. The dog survived, but after hours of emergency surgey. I also knew a fresh out of vet school vet who was trying to fix a cherry eye, and botched it so bad that another vet had to come in and take out the entire eye... Both were otherwise very good vets, and I know they really beat themselves up over their mistakes. I guess the guilt just kinda comes with the job.

There was an intern who was trying to catch a budgie with a net and accidentally hit him mid-flight and killed him... it was very sad, and she couldn't get over that for a long time.

I've also known people who've made mistakes that were in my opinion unforgivable.

My former supervisor euthanized the wrong dog because it was the end of her shift and she just wanted to leave so she didn't check the papework. Needless to say, she was fired.

One of the orgs I worked for had a bunch of red-tailed boas that kept having babies, so they decided to neuter the males... Well... the vet had never done any snake surgeries before, but decided it might be a good idea to go for it anyway. So he looked up papers on snake neuters... and he only found like 1, which didn't even sound very promising, but he still felt like it was a good idea. He opened up the snake but couldn't find the testes, so he kept opening up the snake more, until pretty much the snake was opened up 2/3 of its length. It turns out that no one's written about snake neuters because it's nearly impossible to do. So he decided all of the sudden that he's going to improvise a vasectomy. Yep, no surprise there, the snake died.

There was also a horrible intern that pretty much killed half of the animals she touched... To feed a flegling nighthawk, she forced his beak open so hard that she broke the poor bird's lower jaw and it was just dangling open... You'd think that might be one of those sad tragic accidents that could happen to someone, but she did it again, twice.

Oooh now that I think about it, Candy16, I think I've had a couple of embarrasing surgery prep-shaves myself! I really have no idea what I was thinking, but I had shaved a dog for a neuter but then kept going and shaved his entire tummy as though he was also going in for a spay as well! The vet was more confused than anything (esp because we did have a couple of hermaphroditic cats at this shelter), but laughed really hard after he realized that it was just me being way too razor happy.

Seems like shaving accidents are pretty common haha...I also made a couple of those. Shaved too much on a lion cut, made a small cut with the clippers on the inside of an animal's leg...stuff happens but luckily you learn from it .

One of my friends shaved off a nipple while prepping for a spay and I accidentally shaved off a growth while trying to clip around it.

At a spay/neuter clinic we also mislabeled one of the male cats as a female so we proceeded to shave "her" and prep her for a spay. After about 15 minutes of searching she asked us to double check the sex and sure enough there were 2 testicles . We felt awful for both the vet who had just wasted a bunch of her time and for the cat who had unnecessary abdominal surgery.

The only bright side about mistakes is that you learn what not to do. Sometimes you learn the hard way yourself and someitme hearing what other people have done may prevent you from making that mistake as well.

Been there...

In my early days I pumped a cat full of 200cc subq fluids in a dark room to keep her calm. Too bad I didn't see the bluish tint of the bag that was chlorihexidine, until after I had finished. Cat's fine by the way... Happens to everyone, even the best of them.

I overdosed a cat on insulin once that was just in for boarding.. don't know what I was thinking. Gave it 20 units instead of 2, was thinking the entire time that it seemed strange to give it this much but went ahead with it anyway. As soon as I was pulling the needle out of the cat I had an "Oh crap" moment and ran to tell the vet and she said "Well maybe you shouldn't try to do things you don't know how to do." She ended up taking it home with her to make sure that it made it through the night then took it to an emergency center the next day. The cat was okay so they decided not to tell the owners, but when they put the info in the computer, it automatically added an alert for the receptionists to call to check up on the cat. They did, and the owners had no idea what they were talking about ...whoops. The whole ordeal cost the clinic $400 and lost a client. I had only been there 3 months though.. Heard about a girl that killed a kitten because they turned a cage heater up too high... It's hard but you gotta learn from it and move on.

I haven't made very many mistakes on pets (wildlife is a different story), except for one pretty embarrassing one. I had to give a droncit injection for a dog with tapeworm, and I always hate drawing the stuff out because it's so thick. So I used a pink syringe needle to draw it out since they are a little bigger. I went into the room to inject in front of the client and inserted the needle.The last time I injected droncit I had to use a bit of force when pressing the plunger down since it's thick, but the second I did that , the syringe just exploded and the droncit sprayed all over the place. My face, her face, the ceiling...everywhere. Turns out those pink syringes don't have locks on them. Luckily she wasn't too upset at me, and we had her use the eyewash station just in case.

We don't have any syringes with locks. Is that what most places use?

I did that once with Pen... it was surgery so no one saw but me and the vet. That stuff stinks, and it's hard to clean up!

twelvetigers said:

We don't have any syringes with locks. Is that what most places use?

I did that once with Pen... it was surgery so no one saw but me and the vet. That stuff stinks, and it's hard to clean up!

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Every place I work has some of both. I definitely have a major preference though towards leur lock syringes especially in some of the more "high risk" injection scenarios.

Needle blowing off a syringe during a euth is bad news. Or any injection you are trying to give quick because it stings like an ace/morphine premed for the large aggressive dog or DTK for cats. At least with pen you can just draw up some more.

Save the regular leur tip syringes for the blood draws and catheter injections.

Minnerbelle said:

My former supervisor euthanized the wrong dog because it was the end of her shift and she just wanted to leave so she didn't check the papework. Needless to say, she was fired.

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WOW. You by far had the most stories. You know this stuff happens, but to hear about it and think how it could be your pet.....is terrifying. We are all humans and will make mistakes. I guess we just pray that our mistakes are not catastrophic.

Thanks for sharing everyone. I got the biggest giggle from the shaving accidents including the shaving off of the nipple

I think everyone's shaved off a nipple ... it's pretty common. I work in an emergency clinic and no drug is given without calling it back to either the doc or another tech (That's 2 mgs right? Or, Can you double check my math?). All of our orders are in milligrams, so math mistakes can happen as well.

I personally have never done anything too horrible; and I think our staff is pretty stellar so we haven't made too many mistakes as a whole. However it still happens, even to the best and sharpest.

Bunnity, Ive seen the hole in the crop issue before. Usually its the result of a crop burn that happened a few days earlier and the tissue becomes very fragile. So dont blame yourself. He probably didnt react because he was lethargic from the previous burn.

I was tube feeding a dove once and for no reason the dove freaked out, hyperventilated, regurgitated and died in my hand.. I was like wtf?!! But then I looked him over after and he had a pretty big crop burn at the bottom of his crop coming through his skin.

"Exact"ly

When it heats up sometimes the outside feels cool/warm.. and the inside.. where you are usually drawing from is burning hot... It only takes a few degrees to cause a crop burn. Always mix your formula

I have no clue what you bird people are talkin' about.

I could go on and on about the mistakes I have made and seen. Bottom line mistakes do happen, it is unfortunate but no one is perfect. I was working with a girl who was unfamiliar with IV catheters. A parvo pup ran out of fluids and the vet asked her to clean and flush the IV and start a new bag. The girl grabbed the heparin syringe, locked it in and just pushed....before we could stop her she had pushed a clot and caused an embolism.

As for me, I have accidentally given a small dog 1cc of telazol instead of 0.1cc luckily the dog lived but I was so upset. The vet I worked for was alway in a rush and barking orders at us, I was in such a hurry I didn't stop to think about the dosage. I am also guilty of shaving a nipple off!

1Vista1Grey said:

When it heats up sometimes the outside feels cool/warm.. and the inside.. where you are usually drawing from is burning hot... It only takes a few degrees to cause a crop burn. Always mix your formula

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... and stick your whole finger in it + swirl it around. You'd be amazed at how many little hot spots there can be in a mug full of formula.

Not my story, but my sister's cat was hospitalized for inappropriate urination, loss of appetite, and lethargy.... turned out that her cat had advanced kidney failure and a few other things. The techs were force feeding the cat, it vomited and inhaled it and died. They felt awful, but my sister used to work at a large clinic and understood.

Since my job description doesn't involve much beyond cleaning, stocking, and organizing, I don't often have the opportunity to mess up with animals. I do get called over to help hold animals for nail trims and anal glands, and lately, for blood draws. Still figuring out where to hold off exactly, so needless to say, it usually takes 2 or more tries for them to actually get blood... heh, I always feel bad for making the process take longer and subjecting the animals to more pokes. On the up side, I'm slowly figuring out where to hold off.

I don't know if this is truly a mistake or just a plain dumb move, but one time the our vet tech was restraining a cat and had a 18g syringe in her hand and she uncapped it then put it in her mouth to hold...the wrong way. She pierced her tongue and screamed and the cat dashed off the table, it was awful!

Not to mention extremely painful, which is how I learned not to put needles in your mouth! Hurrah!

twelvetigers said:

I have no clue what you bird people are talkin' about.

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That's OK, me neither!

A few weeks ago, I was dealing with a severely septic neonatal foal who was in isolation. I was in my spacesuit in the stall pretty much the whole time trying to keep the filly from flopping off the mat and getting her lines tangled, and a vet student was helping me by getting drugs, hanging fluids, writing stuff down, etc. The resident came by and hung some bicarb going at a high rate through the pump that she wanted slowed down after an hour. Well, guess who lost track of time (and I couldn't see the bottle to realize, oops, it's disappearing too quickly) and gave the whole bottle super fast! I felt pretty stupid when the resident explained that giving that much sodium that fast was a bad thing in such a sick foal. I think I learned my lesson, though -- if the doctor wants you to change the rate after a certain amount has gone in, set up the pump so that the "volume to be infused" is the amount you want to go in at a higher rate. That way, the pump will stop infusing and beep at you to get you to change the rate. We do that with lidocaine boluses anyway, I just should have asked the resident to do that when she was hanging the bicarb.

I don't really know if that had an effect on the filly, since she continued to circle the drain and we euthanized her a couple hours later. We do NOT have luer lock syringes (you can see where this is going) . . . I had the filly on my lap trying to prop her up so the vet student could get to the catheter. The catheter must have kinked, since all of a sudden there was a lot of resistance and the syringe came off the needle and exploded Beuth. everywhere. I had it all over my face, in my eyes, in my mouth, etc. Fortunately, the filly was so far gone that she did not react to the partial dose we had given her. When we were done, I washed my face off and did not have any effects, but Beuthanasia tastes nasty!

Perfbird, I know someone who uncapped a needle off a syringe of xylazine, crunched the needle cap, and passed out because she absorbed some xylazine, which can drop your blood pressure through the floor.

I have not had a drug error (that I know of!) in a while, but I am extra paranoid about double-checking (sometimes triple-checking) the orders and the syringe to make sure that I am giving the right drug/dose/animal/route/time. I have given Banamine hours early and had to make the embarassing call to the doctor to tell them I screwed up, which is what made me so careful -- I think about what would happen if it were something like gentamicin, which is nephrotoxic. On the flip side, I am somewhat slower than the other nurses because I am so meticulous, and I am more likely to get behind. It makes me nervous, though, to rush myself.