Case study on error in prescribing medication
Published in the December 2017 issue of Vetboard Victoria's newsletter
The following case study provides an opportunity for general reflection. The case study is based on a complaint about an individual set of circumstances at a particular time. As veterinary knowledge and professional and community standards and expectations change over time, readers should not assume that the Vet Board would make the same decision when presented with a similar complaint.
Summary
A nine-year-old cat was presented for a review of his diabetic condition.
Dr S examined the cat and performed serial blood tests to assess his blood glucose levels. Following review of the test results, Dr S mistakenly advised the cat’s owner to increase the insulin dose instead of decreasing it. The cat died that evening.
After a preliminary investigation, the matter was referred to an informal hearing into the professional conduct of Dr S.
In making the decision to refer the matter to an informal hearing, the preliminary investigation panel considered whether the mistake by Dr S could be assessed as negligent, i.e. going beyond a simple reasonable mistake or error. The panel considered that the mistake could be assessed as negligent, and referred it to an informal hearing.
At the informal hearing it was alleged that Dr S prescribed the incorrect dosage of insulin to the cat’s owners for the treatment of his condition, which subsequently resulted in the cat’s death.
Dr S was found to have engaged in unprofessional conduct, and the informal hearing panel determined that Dr S be counselled.
Counselling is a determination that may be made following a finding of unprofessional conduct.
It is a formal process during which the veterinary practitioner is informed of how their conduct failed to meet the minimum required standard and how that standard might be met in future.
A panel may counsel in any way it sees fit. The counselling may be oral, written, given immediately, or given within 28 days of the determination.
Counselling is permanently recorded on the veterinary practitioner’s file and may be referred to in any future hearing or action taken by the Board.
Chain of events
The owner took the cat to the clinic, as the cat had suffered a seizure the night before.
The cat had previously been diagnosed with diabetes by the clinic and was still in the process of weekly blood tests to monitor his condition.
The cat was presented to Dr S, who admitted him for serial blood tests to establish a glucose curve. The results of these tests indicated that the cat’s insulin was too high.
Dr S, in consultation with another practitioner from the clinic, decided to lower the insulin dose to help bring the cat’s glucose levels back to normal.
However, when the owner collected the cat, Dr S incorrectly advised an increase in the insulin dose to 4 units twice daily instead of lowering it to 2 units twice daily.
That evening the cat died, as a likely consequence of the incorrect dose of insulin being administered.
The informal hearing and reasons for finding
The owner described to the informal hearing panel the distress of watching the cat’s violent reaction to the overdose of insulin preceding his death.
Dr S informed the panel that they were on their own at the clinic that day and had been very busy.
Dr S was not able to provide an explanation as to why the owner was given incorrect dosage information, and was extremely upset and remorseful given the outcome.
The panel acknowledged that Dr S was open and honest with the cat’s owner about the error, and Dr S understood the distress caused to the cat’s owner.
The panel considered that both Dr S and the clinic had addressed the situation with open disclosure, acceptance of responsibility, and sensitivity.
For a medical error to be considered negligent, various legal decisions have provided that the relevant conduct must be a substantial departure from reasonably expected standards, and not simply accidental.
While veterinary medicine is a complex field, and veterinary practitioners are not expected to be perfect, in this case the informal hearing panel determined that the error made by Dr S, which resulted in the death of the cat, did not meet the standard expected of a registered veterinary practitioner exercising reasonable skill and care.
Reflections
While not all mistakes will be regarded as unprofessional conduct, the Board is more likely to consider a mistake to be indicative of unprofessional conduct if the error was caused by poor processes, such as inadequate checking, monitoring, or detection processes; or where the consequences were significant for the owner or patient.
The Board may also take into consideration any efforts by a practitioner to mitigate or remediate a situation after detecting an error.
Relevant guidelines