Patient safety and Errors in Veterinary Anesthesia

Veterinary anesthesia is a specialty in which medical errors can lead to significant patient harm. The aim of this thesis was to identify factors contributing to errors in veterinary anesthesia, evaluate the effectiveness of a pre-induction checklist in reducing omission errors, and develop a quality improvement initiative. Four studies were conducted and a Veterinary Anesthesia Error Reporting System was developed. The first study was a literature review on medication errors in veterinary anesthesia. The second study collected voluntarily reported perianesthetic medication errors in small animals. The third and fourth studies were conducted during a live animal teaching session with veterinary students at the University of Calgary’s Faculty of Veterinary Medicine (UCVM). The third study evaluated dose calculation errors, while the fourth study assessed the effectiveness of an anesthesia safety checklist in reducing incomplete safety tasks. Medication errors were found to be the most commonly reported error in veterinary medicine. A medication error rate of 1.8% (48 errors in 2,728 anesthesia/sedation procedures) was identified in veterinary clinics in Calgary. Most reports (69% [33/48]) were near misses (an error that did not reach the patient). Dose calculation errors were the most common type reported; 50% (24/48). During a live animal teaching laboratory session, in which 83 anesthesia procedures were performed, a dose calculation error was identified in 10.8% (9/83) of anesthesia protocols. Furthermore, the use of a pre-induction checklist identified at least 1 omitted pre-induction task in 67.5% (56/83) of anesthesia procedures. The most frequently missed item was premeasuring the endotracheal tube insertion depth (42.2%, 35/83) and the checklist identified closed adjustable pressure-limiting valves in 4.8% (4/83) of cases. A reporting system specific for veterinary anesthesia was developed with the features recommended by the World Health Organization. In conclusion, the results of these studies identified several factors contributing to errors in veterinary anesthesia, with dose calculation errors as major contributor. The results support dose independent double-checking, anesthesia chart reviews, and the use of checklists. Finally, the developed Reporting System received endorsement from an international veterinary anesthesia organisation and shows strong potential as a successful quality improvement initiative.

Name thesis:degree_name

Doctor of Philosophy (PhD)

Discipline thesis:degree_discipline

Veterinary Medical Sciences

Grantor

Veterinary Medicine

Year dc:date.issued

2026

Author dc:creator

• Pinho, Renata Haddad

Advisor dc:contributor.advisor

• Pang, Daniel

Committee members dc:contributor.committeemember

• Pang, Daniel
• Hecker, Kenton
• Mosedale, Pamela
• Tscheng, Dorothy
• Flemons, Ward
• Ho, Certina

• veterinary anesthesia
• adverse events
• medication errors
• dose calculations
• checklist
• reporting system

Statement dc:rights

• Unless otherwise indicated, this material is protected by copyright and has been made available with authorization from the copyright owner. You may use this material in any way that is permitted by the Copyright Act or through licensing that has been assigned to the document. For uses that are not allowable under copyright legislation or licensing, you are required to seek permission.

Language dc:language.iso

en

DOI

https://dx.doi.org/10.11575/PRISM/51069

OAI identifier oai:identifier

oai:ucalgary.scholaris.ca:1880/124095