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Another (Unwelcome) First – Accidental Chemo Overdose

 

Honestly. Every time I think Lilly’s medical saga cannot get any worse, something else that’s unexpected / unwelcome happens. On top of the not-good kidney news from earlier this week, on top of figuring out Lilly still has high blood pressure (even though she has been on BP meds since February 2012) … Lilly received an accidental “overdose” of cytarabine (a chemo drug) Wednesday night.

I won’t bog you down with dosage calculations for cytarabine’s use in non-cancer neurology cases. Here are the plain numbers:

  • 34 mg ~ Lilly’s normal sub-q cytarabine injection dose
  • 58 mg ~ Dose Lilly got Wednesday night because of a mistake

It turns out there was another dog coming into the hospital for an injection Wednesday night. That dog’s dose had already been drawn into a syringe. It was accidentally given to Lilly instead.

Lilly got 24 mg MORE cytarabine than she should have.

  • 58 minus 34 = 24
  • 24 divided by 34 = .705
  • About 70% too much

That’s the bad news.

The good news, however, is that cytarabine is used (obviously) in canine cancer patients in MUCH higher doses. Whereas Lilly gets 4 injections in each cycle, canine cancer patients get 6 injections of much higher doses in each cycle.

In other words, the one mistake dose Lilly got is NOT way out of safe ranges for how this drug is commonly used in dogs.

Is it more than she should have gotten? Absolutely.

Is it going to cause problems? We don’t think so. We hope not.

Now, in my imagination — of course — Lilly does seem off. She is sleeping a lot. She seems to be breathing heavily and panting more.

Is Lilly really off from the accidental overdose? No idea.

Cytarabine doesn’t reach full effect for about a week, so we’ll keep a close eye on Lilly until then. If I think she needs an exam, if I’d feel better if they drew a CBC next week to make sure her red cell count is still OK, they’ll do that for free.

So, we’ll see.

I am keeping Lilly close, and I am checking her temperature once a day, just in case. Thursday, she spent most of the day in her crate looking like this.

best dog blog champion of my heart border collie in crate

Friday, so far, she has spent more time sleeping under my desk. Though, as I write this … she is back in her crate.

best dog blog champion of my heart border collie sleeping on dog bed

The Back Story

I didn’t learn about the medical mistake until about an hour after it happened. Here is how the encounter looked from my vantage point.

As always, we arrive a few minutes before Lilly’s 7 pm “technician appointment” to receive her injection. As always, even though the front desk team seems to recognize us, I announce, “Lilly Hawn, here for a cytarabine injection.”

When the technician (who has given Lilly injections before) comes out, she asks for Kelly, not Lilly. The conversation goes something like this.

Me: “You mean Lilly.”

Her: “For an injection?”

Me: “Yes, cytarabine, but it’s Lilly not Kelly.”

I go on to ask if she has the time to check Lilly’s blood pressure. Since high blood pressure could be a contributing factor in Lilly’s new kidney trouble, I wanted to know what her BP was. I honestly don’t remember anyone ever checking Lilly’s blood pressure since the night it was so high in February 2012 that we started BP meds.

As we walk back to an exam room to take Lilly’s BP, the technician again says something like, “I must have heard it wrong. Kelly instead of Lilly.”

I say something like, “Well, they both have 2 L’s in them,” and we laugh.

We spend several minutes on the floor together, taking Lilly’s blood pressure several times so that we can calculate an average. Both of us pet Lilly and talk to her in soothing tones — using her name again and again — hoping she will calm down so that we can get an accurate reading.

When we’re done, the technician takes Lilly to the back (as usual) for her injection, and I wait out in the lobby.

A veterinary assistant brings Lilly back out to me, and I put her in the car, while I go back in to pay.

Now, the hullabaloo about how these appointments get scheduled and how they get invoiced is a story for another day. Suffice it to say that when almost everyone I encounter is stumped about it, it’s easy to assume that Lilly is the ONLY dog getting a treatment like this. Honestly, the invoice is almost never ready, so we’ve taken to putting a credit card on file at the hospital, and the billing department charges me later.

BUT, while we’re waiting / hoping that the invoice will be ready, I’m told that the technician is making me a blood pressure chart, if I could just wait a bit.

So, I wait … and wait … and wait ~~ while listening to the heartbreak of a family in the ER who brought in their kitty who had been hit by a car (and was euthanized).

I’m getting tired. Remember, Lilly gets us up around 4:30-5 am every day. I’ve written / worked ALL day. It’s getting close to 8 pm, and I’m exhausted and still have a long drive back up the mountain.

I ask at the desk, if maybe they could email me the blood pressure chart and as before just charge my card when the $$ part gets worked out. They say, “Yes.”

But, then the technician is right there and says one of the ER doctors wants to talk to me about Lilly’s blood pressure results.

So, back into an exam room I go to wait. I call Tom to let him know what’s going on so that he doesn’t worry. We should have been home by now.

Indeed, an ER doc I’d not yet met comes in. We bond over her experience losing her heart dog, after a complicated 5-year illness. We talk about what Lilly’s blood pressure results mean, etc.

Then, that’s when I hear the news about the medical mistake.

Honestly, it came as such a surprise, and I was so tired, and I knew I had a monster work day coming up Thursday, and I knew I needed a good night’s sleep.

My theory was that if I understood the extent of the overdose that I wouldn’t sleep, so I didn’t ask. Considering the last 18 months, considering the last week, considering the news of the error, my confidence was shaken.

I waited to ask those questions until Thursday morning. That’s how I got the details you see above.

What’s the lesson?

If anyone ever comes out and calls your dog by the wrong name,
throw a flag on the play.
Don’t assume it’s just a name mistake.
It could be an actual patient mix-up.

Obviously, the hospital is putting some changes in place to prevent a mistake like this from happening again.

I’m not sure what the solution is, but I:

  • May make Lilly a bandana with her name on it
  • May start telling the person taking her back what her normal dose is

Other ideas?

 

 

Roxanne Hawn

Trained as a traditional journalist and based in the Rocky Mountains of Colorado, USA, I'm a full-time freelance writer for magazines, websites, and private clients. My areas of specialty include everything in the lifestyles arena, including health and home, personal finance and other consumer interests, relationships and trends, people and business profiles ... and, of course, all things pet related. I don't just love dogs. I need them in my life. Seriously.

Regret A Vet - July 29, 2013

This is very serious. Your dog made it through a “mistake” but some other pet might not have. By being so laid back about it you were the perfect kind of client so they can use the old “We will be making some changes Mrs. Jones to prevent this from ever happening again.” (That’s a crock!) After they knew they were off the hook they grabbed the towels to wipe their sweaty heads! This is something that should have been reported to the state board. Who knows how many mistakes they have already made? Who knows how many are to come again from carelessness? Do you honestly think your the 1st mistake they made. The only thing that MIGHT change them is a slap on the wrist from the board. Which is also ALL they would get had your dog died from this. I find it sad that you felt you had to ask if they had the time to check Lilly’s blood pressure. You should never have to ask someone to do whats in their job description, it’s your appointment and your paying for it. As for “OTHER IDEAS”…..YES! Never go back there again and warn others. I’m SO happy your dog made it through this. I’m sad for the dogs they will injure or kill in the future. Everyone makes mistakes and I understand that. But there are consequences and just because they have a MD or DVM after their name doesn’t mean they are an exception to the rule.

Kelly - July 14, 2013

I tape a card to my dog’s leash which says, ” I am here for… and then the specifics.”
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The Zoo - July 6, 2013

We’re sorry for all you and Lilly are going thru.
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Hawk aka BrownDog - June 23, 2013

Hi Y’all,
Anytime a human goes in for any procedure, in our neck of the woods, whether a hospital or outpatient facility, they get a wrist band that they are asked to check before it is put on. Before any drug or whatever is needed is done, the band is scanned along with the nurses badge code. In the hospital and cancer center the drugs are not dispensed until the nurse scans the patient’s wrist band into the computer. At that time they are dispensed from the pharmacy.

Sounds like vets need to follow this kind of procedure for their patients. Thanks for the warning. Prayers that Lily is not affected adversely by this mistake.

BrownDog’s Human
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Cybele - June 23, 2013

Posting here because I don’t use Facebook:

Please accept my deepest condolences at the loss of your mother. A day doesn’t go by when I don’t think of my own who’s been gone 7 years. Stay strong. You have so much on your plate as it is.

Sam - June 20, 2013

OMGosh! How scary. I would maybe repeat your last name? Ask them to double check their charts? The tech should have automatically checked when the names weren’t correct. Maybe talk to the vet aobut changing their procedure? Our vet labels shots – nothing fancy, but when it is drawn it gets a name and number on it. Then they ask us to verify the name.

Sam
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Lisa Spector - June 18, 2013

I can’t believe all that you have been through Roxanne. You are so resilient and inspirational. I’m very impressed that you kept your cool and waited til Thursday morning to ask more questions.

I hope the Vet clinic at least didn’t charge you for that visit, given their major error.

Kisses to Lilly and hugs to you.

Kyla Duffy - June 15, 2013

I apologize if this is a question you have addresses in a previous post, but why don’t you go to a different vet? I’m appalled that the tech can’t even get Lilly’s name right.

We had a similar situation that almost killed my sister when she was having cancer treatments at Children’s Hospital in Philadelphia 31 years ago. The nurse was carrying bags of two different blood types for two different patients who needed transfusions, and she gave the wrong bag to the wrong patient. From that day forward, the hospital instituted a policy that a nurse couldn’t carry two blood bags at once.
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Jen - June 15, 2013

I agree with others, that you should ask to see the chart/computer screen to make sure they’re referencing the correct patient (i.e., YOUR DOG). Oh God. I do hope that, since the dosage was still well within normal “safe” range for dogs under chemo treatment, that it doesn’t affect Lilly poorly. Like she needs that 🙁

I also think that a bandanna (or collar!) with her name on it big and apparent is a good idea, and also telling them what her normal dose is. That’s so scary.
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Jane Boursaw - June 15, 2013

Oh good grief. So sorry you’re having to deal with THIS on top of everything else. Hard to keep track of everything when you’re so exhausted all the time. The vet people should have double-checked to make sure they were giving the right dog the right dose, but that’s probably a pipe dream that that would actually happen.

Though it does bring back vivid memories of me having to read nurse’s charts on the sly when my husband was spending a lot of time in hospitals for a chronic illness – just to make sure everything was happening that was supposed to happen. Sigh…
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TheDogMaOnline,llc. - June 15, 2013

Dear Roxanne,

You are incredible and such a wonderful caretaker.
We are firm believers in detoxification. Especially in a circumstance as this. I’m sharing this information in the hopes that you will see the benefits of ridding Lilly of the toxins her treatments are giving her. If we can help in anyway, please let us know. https://www.thedogmaonline.com/Miracle_Minerals_Detox.html

Jan K - June 15, 2013

I admire how strong you stay through all your stress and exhaustion. This story reminded me of when I had surgery on my hand….I encountered numerous doctors and nurses and each and every one confirmed my name and date of birth. It seems the vet clinic needs to come up with the same type of protocol. I imagine they will after this happened. But for your peace of mind you should do the things you thought of…confirm with the tech Lilly’s name and dosage before they take her back (if you can’t go with her). They can’t fault you for that after what happened.
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Sue at Talking Dogs - June 15, 2013

I learned a long time ago to check and re-check the details when anything “important” is happening. My mom was in the hospital for cancer surgery and they toe-tagged her for a gall bladder procedure. Luckily, I read the tag… I don’t care if someone calls me paranoid, I check and re-check in any medical situation.
Hoping this will not mean a set-back for Lily!
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Debra Jones - June 14, 2013

Roxanne, I don’t know if I would have them bring out the chemo injection and give it right in front of you – it is a toxin. I would suggest the staff come up with an ID check – name, date of birth, sex, breed, color – two things to check to make sure they are injecting the correct animal. Also, dosage should be included on the syringe… i.e., Lilly/border collie/DOB 5/5/05
Cytarabine 34mg – the above info on syringe should be repeated by the tech and compared to Lilly’s chemo order. Just a thought – as an Oncology Nurse, we have two ID checks plus the chemo drug’s information is compared to original dosage order and/or updated order. The Tech should tell you exactly what info is typed on the syringe. Just saying…. Making a chemo mistake turns my stomach and gives me chills….

Vicki Cook - June 14, 2013

Wow Rox – I’m sorry to hear you had another curve ball thrown at you. Hopefully, Lilly will be alright. I agree with Carol and would ask to see her chart when they come out for her so you know they’re getting the right dog. I certainly hope they are more careful in the future!
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Jana Rade - June 14, 2013

Hoping no complications arise from this mistake!

Don’t they tag/label or otherwise identify the injections once drawn? The mix up certainly did sound like it didn’t mean anything, particularly since the names were somewhat similar.

One can never be on their toes enough, can they?

(((hugs)))

Carol Bryant - June 14, 2013

Oh my God, just when you cannot think anything else can possibly happen. My heart comes out to you. Gosh, I guess have a parade and shout loudly, “This is Lily.” I’d be beside myself.
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Pamela - June 14, 2013

Hope Lilly gets some of her spirit back soon so you can know for sure that the overdose didn’t hurt her.

Unfortunately, these kinds of errors are common in human and animal hospitals and hard to fix. Since the vet discovered the error, hopefully they’ll be more vigilant in the future.
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Carol V - June 14, 2013

Ask to see the actual chart or the computer screen if it’s electronic records…and when they look at you “funny” tell them why!!! As an xray tech (now retired) I once went out to the waiting room to call my next patient who needed a hand xray, and I called his name and a man stood up and followed me into the room. When I asked him to sit on a stool at the end of the xray table and put his hand on the film holder he said “why are you pointing the machine at my hand when i need a chest xray?” No harm this time..but soon after this we started giving our patients a name card to give to us to verify we had the wrong patient. Humans make mistakes, it’s unavoidable, but there are things to make them happen less often! I second the name on the bandana! But the medical peeps need to be alert and pay attention!

Christine - June 14, 2013

There’s no reason not to bring the syringe forward, show it to you, and give the injection to your dog in front of you. Unless your dog is much worse behaved in your presence than otherwise, I would insist on being present for future injections.

    Trish - June 17, 2013

    This is a chemo drug…I don’t think they are, or should be, allowed to inject it with the owner present. They are probably gowned with chemical resistant gowns, double gloved, with a mask/eye protection while preparing, and injecting, the medication.
    That being said, reminding them of the dose, and the bandana, is never a bad idea. And asking to see her chart before and after shouldn’t be a problem either.

Penny Ronning - June 14, 2013

Ask for a visual confirmation of the chart/orders and the actual syringe with the medication for both you and the tech to see.

Mary-Alice - June 14, 2013

Maybe have them come out with the syringe, just before the shot, and let you have a visual confirm that it’s the right dose? Dang, girl — so glad it was a thing that sounds like it’ll ultimately be okay. Given the stuff you’re working with, this could have been an even scarier story. Love to you guys!
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