ICU was busy last week. We had the usual assortment of trauma, infections and various other conditions to manage. It was not lethally busy, where I fear the caseload will overwhelm the caregivers and lead to substandard care (or worse), but busy enough that you had to keep moving, dodge bullets, dance with death, and think on the fly.
I had a patient who required a bronchodilator, a medication that’s a distant relative of caffeine, and aids breathing by opening up lung passages and strengthening the muscles of respiration.
The medication, terbutaline, is a pretty commonly used one and has a reasonable safety profile; it’s hard to harm a patient with it, even with an overdose. The effects of an overdose are nervousness, rapid heart rate and possibly an irregular heart rhythm, like having a couple of grande cappuccinos floating around your system. Not pleasant, to be sure, but probably not going to hasten your demise, either.
At the time I wrote the order, I was preoccupied with getting this patient in for a CT scan and trying to organize all the various services that go into this — radiology to perform the scan, neurology to interpret the scan and anesthesia to keep her alive and anesthetized during the scan. I had many plates spinning, plus a few other ICU patients I was making decisions on at the same time.
I had not used terbutaline in a while, so I looked up the dose in our ICU formulary (a book that lists information about drugs, along with the doses) and did the calculations in my head.
The formulary lists the dose as 0.01 milligrams per kilogram (or mg/kg) and the patient weighed 4 kg. The total dose should have been 0.04 mg, but somehow I dropped a 0 and ended up with 0.4mg – a 10-times overdose. I wrote this erroneous dose on the treatment sheet and asked the student to go to the pharmacy and retrieve the drug.
I then went back about the logistical routine of what I call the “poultry alignment process,” or getting my ducks in a row. I had a narrow window to get this patient in for a CT scan, and I didn’t want to miss the opportunity. I felt like a bike messenger delivering an important parcel, and dodging taxis, cars and buses along the way; I had to the thread the needle just right to get the CT coordinated.
In my haste and distraction, I didn’t notice the wrong dose. Luckily for my patient, and for me, the student did. She came back from the pharmacy and said, “Shouldn’t the dose be 0.04 ml, instead of 0.4ml?” I went back to the formulary and confirmed that I had made an error, and thanked her for being on the ball.
Her CT went off as planned, and she recovered well from her malady.
In this particular case, the error was caught, the overdose avoided and the proper dose given. Even if the overdose had been given (I told myself), the patient would likely not have been worse off, just a tad nervous.
But, I realize that it could have been far worse — if it had been another drug, like potassium chloride (a commonly used fluid supplement) or propofol (an anesthetic) I could have mistakenly written an order for a lethal dose.
My error could have killed someone’s pet.
For humans, medical errors injure more than 1.5 million people a year and result in 7000 deaths. No one knows the number of times it happens for for pets, or how many lose their lives as a result, but the numbers are certainly comparable. The government keeps numbers for human medical errors, but their attention for animals is usually limited to making sure they are relatively safe to eat.
We have a review process for serious medical errors here, and I am a firm believer in full disclosure for pet owners when it does happen. I am also a believer in apologizing for errors, but lawyers often advise against it because they see it as an admission of guilt. Recent thinking on the topic, though, has shown that people who were harmed by a medical error are actually less likely to sue if they receive a sincere apology. To me, it just seems like the right thing to do.
Luckily, I have only had to do this once, and it was not a direct error on my part. I was the attending on the case, though, so I was responsible. The owners took it well in that case and were understanding (their pet was not harmed by the mistake).
Not every error results in harm to the patient. There is a huge dose range for most drugs (sometimes as much as a 10-fold variation in how much drug we can give) and animals and humans have a tremendous capacity for staying healthy despite our efforts to the contrary.
All these facts about a patient resistance to harm and dose ranges smacks of whistling in the dark to me, however. These are the things I tell myself so I feel like I am doing more good than harm, on balance.
This time, we both got lucky. I know I will be on high alert for a while, but eventually I risk falling back into old rhythms. I can only hope that I have another astute student to help me avoid harming my patient the next time it happens.
Photo: My patient in the CT scanner
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Yesterday at the Kindred Spirits Dog Training yard I decided to cut a bouquet of roses before getting ready for the puppy class.
I called out to him, “What’s wrong, Sisko?” I thought maybe he got stung by a bee.
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Photo ©Mark Rogers Photography 2011, All Rights Reserved
Veterinary Practice News reported tonight that Pfizer is pulling its flea and tick preventive, ProMeris for Dogs, from production after it was linked to cases of a serious canine skin infection known as Pemphigus foliaceus (PF).