Accidental intraarterial propofol injection in a dog.

Medication errors are the most common type of medical error in veterinary medicine, with drug delivery by the wrong route comprising 8% of medication errors. A healthy, 4-year-old, 13 kg, mixed breed female dog was admitted for elbow surgery. After premedication (dexmedetomidine 0.5 μg kg-1, methadone 0.3 mg kg-1 and alfaxalone 0.5 mg kg-1 intramuscularly), general anaesthesia was induced with alfaxalone (1 mg kg-1) injected intravenously through a catheter placed in the right saphenous vein. Anaesthesia was maintained with isoflurane in oxygen. Physiological monitoring comprised electrocardiography, noninvasive arterial blood pressure, capnography and pulse oximetry. A catheter was placed in the left dorsal metatarsal artery for planned arterial blood pressure monitoring intraoperatively and an injection port attached. While waiting for transfer to surgery, anaesthesia was monitored by a student. When the dog spontaneously moved, the student was unsure what to do and the supervising anaesthetist injected propofol (1 mg kg-1) into an injection port, believing it to be attached to an intravenous catheter. Depth of anaesthesia was corrected. Thirty minutes later, white fluid was noticed in the hub of the intraarterial (IA) catheter when the injection port was removed to connect the extension line, prompting a realization that propofol had been injected IA. Physiological variables, the IA catheter and the anaesthetic record were examined. A slight reduction in HR was the only change following IA propofol injection. No further complications occurred. Following investigation, four potential factors contributing to the medication error were identified: 1) individual - distraction; 2) surgical procedure - unusual intravenous catheter location; 3) organization - shortage of appropriately trained personnel to monitor anaesthesia due to miscommunication between anaesthesia and surgery services; and 4) organization - standard practice to not label IA catheters until the postoperative period. Mandatory IA catheter labelling immediately after placement and improved interdisciplinary communication were implemented at the institution.