Case 33: Glioblastoma

Hübler, Anke; Hänsel, Mike; Domino, Karen B.; Hübler, Matthias

doi:10.1007/978-3-642-45407-3_33

Cited by 1 publication

(1 citation statement)

References 8 publications

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“…There are multiple causes leading to medication errors, including faulty labelling and a lack of vigilance 11. When the activity level of the person administering the medication is either too low or too high, there is an increased likelihood that the person sees what he or she wants to see (‘I am giving the right drug’) rather than what really is there to see—even if there is conflicting information present, such as a syringe that is smaller than expected 12. A horse moving on the table is not an unusual situation for an equine anaesthetist, but yet it causes a sudden increase in the activity and arousal level of the anaesthetist, making the anaesthetist more vulnerable to this type of error.…”

Section: Discussionmentioning

confidence: 99%

Accidental overdose of intravenously injected unfractionated heparin followed by prolonged clotting times in an anaesthetised Shetland pony

Pekkola¹,

Braun²,

Menzies³

2018

Vet Rec Case Rep

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A six-year-old Shetland pony stallion was presented for elective castration. During surgical preparations, undiluted heparin (120 iu/kg) was unintentionally used for intravenous catheter flushing instead of heparinised saline solution. Surgery was cancelled for that day. Thromboelastography was used to monitor blood coagulation immediately after the accidental heparin overdose and on the following days. Three days after the heparin overdose, the coagulation parameters had returned to normal values and the pony was castrated. Anaesthesia and surgery were uneventful without any signs of coagulopathy. One day after surgery, the pony started to show signs of colic and was further diagnosed with colitis, most likely unrelated to heparin but due to repeated administration of penicillin and anaesthesia. Despite intensive treatment, the pony deteriorated progressively and was euthanased due to poor prognosis. Drug overdose is an example of medication error and is one of the most common errors in medicine.

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Section: Discussionmentioning

confidence: 99%