College Connection | Fall 2024
Panel takes no action in case involving human error
College Connection | Fall 2024
LEARNING IN PRACTICE
Panel takes no action in case involving human error
Case Summary
The member examined and vaccinated a puppy . Once the vaccines were given , it was noted the puppy had inadvertently been given a feline vaccine , rather than a combination vaccine for dogs . The vaccine manufacturer was contacted for advice and the client was immediately informed of the error .
Case Outcomes
The Complaints Committee panel decided the allegations , although serious , did not warrant a referral to the Discipline Committee . The panel decided not to take any action .
Case Considerations
In considering the complaint , the Complaints Committee panel reviewed medical records and written submissions . As is standard for all investigations , the panel considered previous proceedings , if any .
The member indicated they contacted the client to discuss vaccine protocol , deworming and a previous positive giardia antigen test . Due to pandemic restrictions , clients were not permitted in the hospital with their pets . The clients agreed to do the DA2PP booster and the first dose of the leptospirosis vaccine .
The member asked the veterinary technician to draw up the vaccines and when the vaccine was administered , they noticed it was the HCP vaccine , due to the vaccine vials and stickers . The member called the manufacturer to discuss the error . The member , as per the manufacturer ’ s advice , recommended holding off on the DA2PP vaccine for two weeks . An appointment was made for the DA2PP vaccine at no charge .
The member explained staff draw up vaccines according to the veterinarian ’ s instructions . To avoid another error , vaccines are now being drawn up by veterinarians . In addition , identifying stickers from the vaccine vials will be placed on the syringe at the time of preparation , so the contents of the syringe can readily be verified . The contents of the syringe will be reviewed prior to administration to ensure accuracy .
The panel agreed that administering the wrong vaccine appeared to be an inadvertent human error . The member and staff took the error seriously and instituted vaccination protocols to mitigate against such an error occurring in the future . Fortunately , in this case it did not appear that administering the wrong vaccine had serious consequences for the puppy .
Another aspect of the complaint related to hospital ’ s business practices in charging the full amount for the visit . The College does not regulate veterinarians ’ fees and does not have the authority to compel veterinary clinics to adjust their fees or offer refunds . There is an expectation that the fees charged for veterinary services are reasonable and veterinarians behave in a professional manner . In this case , the member offered to administer the DA2PP vaccine in two weeks at no additional charge .
The client chose not to continue care at this hospital . The member refunded the cost of the treatment that was not provided and transferred the puppy ’ s medical records to the new practice .
The panel acknowledged that during the course of a veterinarian ’ s career , errors do occur . Errors are not necessarily reflective of poor training , skills or knowledge . Typically , they are inadvertent human errors .
It is unfortunate the incorrect vaccine was administered to the puppy . It is a relief there did not appear to be any significant consequences as a result of this error .
The panel expects veterinarians to exercise caution when carrying out their duties given that , depending on the nature of the error , consequences can be substantial . The panel expects that when an error is discovered , the owner is informed in a prompt manner and appropriate steps are taken to address the issue and ensure it does not occur again .
Veterinarians have a responsibility to provide safe , quality care . The College assists veterinarians in doing so when matters are reviewed by the Complaints Committee . The public has a right to ask questions about the care that was provided to their animal ( s ) and this process provides veterinarians with feedback on whether they have met the standards of practice or whether there are improvements needed to mitigate risks in practice . The Committee provides advice or may request a veterinarian enter into an undertaking when remediation would reduce risks and support a veterinarian in meeting the standard of practice . Only the most serious cases , where there is bad intent , incompetence , reckless behaviour , or a history of failure to remediate at-risk behaviour are referred to the Discipline Committee for a discipline hearing to determine if an act of professional misconduct or serious neglect may have occurred . This example is taken from a case that was reviewed by the Complaints Committee and is offered as a self-reflection tool to support veterinarians in understanding how to meet the standards of practice .
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