Case study: Dispensing error

27 March 2024

A veterinarian prescribed Carprofen (20mg) for a dog that had a surgical procedure in their clinic. Another veterinarian then dispensed the medication incorrectly giving the dog’s owner Carprofen (100mg). The client administered it to their dog several times before realising the dosage was incorrect. Their dog experienced side effects from the higher dose, and the owner made a complaint to the Vet Council.

The veterinarian who made the dispensing error was not actively involved with the dog’s case management and was not the treating veterinarian.

The dog owner’s complaint was referred to the Notification Review Group (NRG) which triages and screens notifications to identify areas of concern, and see if further action is required.

When considering the case, the NRG looked at the Veterinary Medicines section of the Code of Professional Conduct, which says veterinarians must be satisfied that the choice and use of a veterinary medicine is justified and that it is appropriate to achieve the intended outcome for the welfare of the animal. The NRG also referred to the Veterinary Services part of the Code, which says that veterinarians are expected to have high standards of expertise and performance. Section 3 details that all veterinarians must take reasonable care to ensure that they practice at the standard expected in the Code.

The NRG considered that this case put the dispensing veterinarian in a challenging position because they were responsible for handling and dispensing medication for a case they had not previously been involved with.

 In their response to the NRG, the veterinarian apologised for the error and took responsibility for the mistake. They outlined how they would approach the case differently next time which included:

The NRG acknowledged that these types of mistakes do happen from time to time, and they commended the veterinarian’s proactive approach and engagement with the NRG process. The NRG did not believe that the complaint reflected adversely on the veterinarian’s fitness to practise and that the changes made at an individual level mitigated the potential for future reoccurrences. It determined no further action was required.

The NRG believed that the veterinarian took time to reflect on the complaint and think of changes that could be made at a clinic level. In particular, introducing a dual checking system involving a second person checking that the medication being dispensed matched the medication prescribed.

A dual checking system adds another layer of scrutiny and helps prevent dispensing issues similar to this from occurring. This type of system is even more important when new or inexperienced veterinarians are involved, or where veterinarians responsible for prescribing medication haven’t been involved in the patient’s care.