Medical Error Rate In Small Animal Practice

Hello, Summarians!

Everyone makes mistakes. How many is a sticky question. Like all of them, this study is likely underestimating as it was self-reported. Still, it gives some ideas about what can be done to improve this issue.

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Bute Dose Changes for Older Horse?

With advancing age, hepatic drug metabolism and renal function decline, reducing drug elimination and increasing toxicity risk in older animals. For example, drugs metabolized by the cytochrome P450 (CYP) system or excreted renally have an elimination half-life 50% to 75% longer in patients aged 65 or older. Similarly, older alpacas exhibit slower clearance of renally eliminated gentamicin compared to younger ones. Age-related physiological changes affecting drug distribution, metabolism, and elimination include decreased plasma protein binding, reduced total body water, and declining liver and renal function. Such studies in horses are lacking, necessitating pharmacokinetic studies in geriatric horses to minimize adverse drug reactions. 

Phenylbutazone (PBZ) is a nonselective cyclooxygenase inhibitor used in horses for pain and inflammation. However, it is associated with ulcerogenic effects and potential toxicity in the alimentary tract, especially with high doses and prolonged use, posing risks for geriatric horses, which often require long-term treatment for orthopedic issues. 

Drug-metabolizing enzyme activity, affected by factors such as age, was evaluated in horses, revealing lower oxidative pathway activity in juveniles but no differences in older horses. Previous studies did not focus on geriatric horses, highlighting the need for such research to determine optimal drug dosages. 

A single-dose crossover study examined PBZ pharmacokinetics in young and adult ponies, showing reduced clearance in adults, supporting the need to assess PBZ in geriatric horses. This study aimed to evaluate the pharmacokinetic profile of PBZ and its metabolite oxyphenbutazone (OPBZ) in geriatric versus young adult horses, hypothesizing age-related differences. 

A two-compartment model fitted PBZ plasma concentrations, aligning with previous studies. Pharmacokinetic parameters for young adults were consistent with literature, and no significant differences were found between young and geriatric horses. Similar findings were reported for naproxen in older horses. 

PBZ elimination depends on hepatic metabolism, with OPBZ and γ-hydroxyphenylbutazone being significant metabolites. Age-related hepatic CYP activity alterations could affect PBZ elimination, increasing toxicity risk. PBZ binding to plasma proteins is high, and a reduction in plasma albumin could increase free drug concentration, although such decreases are not documented in horses. 

In this study, OPBZ plasma concentrations were analyzed, showing no significant difference in metabolite elimination rate between age groups. The AUC ratio of the metabolite to the parent drug was about 20% for both groups, consistent with previous findings. 

In conclusion, no significant difference was found in PBZ disposition between geriatric and young adult horses, indicating no need for dose adjustments in healthy geriatric horses based on the current FDA-approved dose. 

Zaghloul, I. Y., Bedenice, D., Ceresia, M. L., Jones, P. H., Sanchez-Londono, A., Lobo, M. N., Böhlke, M., & Paradis, M. R. (2024). Comparative pharmacokinetics of phenylbutazone in healthy young-adult and geriatric horses. American Journal of Veterinary Research https://doi.org/10.2460/ajvr.24.01.0012 

Bottom line — dose change does not seem to be needed.

Medical Error Rate in Small Animal Practice.

Medical errors (MEs) significantly increase patient harm and death risks in both human and veterinary medicine, with medication errors representing over 40% to 60% of medical errors. These errors occur across all medication preparation stages, including prescribing, preparing, dispensing, administering, and documenting. 

The perianesthetic period, particularly high-risk for MEs, includes stages such as premedication, induction, maintenance, recovery, and postoperative. Despite anesthesia representing a small proportion (approx. 2%) of insurance claims, its risks are notable due to anesthetic drug characteristics, IV administration, and complex calculations for individual doses, especially in veterinary patients. 

Recognizing and identifying error types and contributing factors are crucial for improving patient safety. Most MEs are reported through self-reporting systems, which can miss many errors, particularly near misses. Near misses, although not resulting in patient harm, are valuable for identifying factors preventing errors from reaching patients. 

Previous studies have focused on veterinary teaching hospitals, but this study examined perianesthetic MEs in general practice small animal veterinary clinics. The study found a higher incidence of MEs (1.8%) in general practices compared to veterinary and human teaching hospitals. Of the reported errors, 69% were near misses, higher than previously reported rates in veterinary medicine but consistent with some human medicine studies. 

Wrong dose errors, primarily from calculation and syringe filling errors, were the most common MEs. Calculation errors often stem from unit conversion mistakes and insufficient basic mathematical skills, highlighting a need for education on drug calculation skills. Strategies like independent double-checking calculations and using dose calculation applications can help reduce these errors. 

The study found most MEs occurred during prescribing, with technicians frequently involved in both ME occurrence and discovery. Excessive workload was a common contributing factor, underscoring the need to address staff workload and promote teamwork and communication. 

Limitations of the study include incomplete reporting and reliance on voluntary reports, which likely underestimate the actual incidence of errors. The study emphasizes the need for specific, relevant questions in reporting systems to ensure consistent data collection. Sharing ME data more widely in veterinary medicine would raise awareness, promote a safety culture, identify common causes of errors, and drive quality improvement. 

Pinho, R. H., Tscheng, D., Cheema, J. S., & Pang, D. S. J. (2024). Incidence and type of voluntary reported perianesthetic medication errors in community veterinary clinics in Calgary, Canada. American Journal of Veterinary Research https://doi.org/10.2460/ajvr.24.04.0119 

Bottom line — Very typical rates compared to human medicine. Education is the key to prevention.

Novel Nitric Oxide Wound Dressing

Open wound management, particularly for traumatic wounds, is complex and costly, requiring precise treatment due to the multifaceted nature of wound healing. The process involves angiogenesis, inflammation, cell proliferation, matrix deposition, and tissue remodeling. Topical dressings, like hydrogel, alginate, and antimicrobial dressings, each support specific phases of wound healing. Nitric oxide (NO) plays a vital role in wound healing across all phases, promoting antibacterial activity, granulation tissue formation, and collagen maturation. 

A study evaluated a novel NO-based wound dressing for managing traumatic wounds in dogs. This dressing, available as a pad and a dehydrated gel precursor, generates NO through the reduction of sodium nitrite in saline. The study found the NO wound dressing easy to use with no direct complications affecting the dogs. The majority of wounds healed successfully, with only three instances of dehiscence attributed to factors such as tension, compliance issues, and possible infection. 

The study highlighted the NO dressing's broad-spectrum antibacterial activity and its potential to lower infection rates. However, limitations included the subjective assessment of wounds, lack of a control group, variability in clinician experience, and the absence of chronic wound cases. The study suggests that NO wound dressings could simplify open wound management, warranting further research on their efficacy in chronic wounds. 

In summary, the novel NO wound dressing shows promise in managing acute traumatic wounds in dogs, offering a potentially simpler approach to wound care with various formulations suitable for different wound types. 

Marvel, S. J., Goldblatt, B., MacPhail, C. M., & Zersen, K. M. (2024). The use of a novel nitric oxide wound dressing in acute traumatic wounds in dogs. American Journal of Veterinary Research https://doi.org/10.2460/ajvr.24.04.0124 

Bottom line — Potentially useful for dogs.

Just putting things in perspective …