Veterinary Medicine
Aiya Almogaber, PharmD
A study published February 25, 2025, in JAPhA sheds light on the frequency and nature of medication errors in veterinary hospitals, where pharmacists are often absent from routine care.
Researchers analyzed incident reports over a nearly 4-year span at a veterinary teaching hospital. Those reports revealed that dosing mistakes were the most common type of error and that certain frequently used medications were disproportionately involved. These findings raise important questions about how pharmacist involvement could help improve medication safety in animal care settings, specifically how chart reviews may play an important role in improving medication safety in veterinary settings.
Frequent errors and high-risk medications
Researchers reviewed 1,031 incident reports submitted between July 2019 and March 2023 across both small and large animal services. Of these, two-thirds (66%) were medication-related, with incorrect dosing accounting for more than half (51%) of those reports. Additional error types included wrong drug, wrong patient, wrong route, as well as documentation issues.
Gabapentin, methadone, and vaccines were the most frequently cited medications in error reports. These drugs were also among the most commonly dispensed during the study period. Gabapentin alone was dispensed over 10,000 times over the study period, suggesting that high volume may be a contributing factor in error frequency.
Pharmacist chart review
The research team also examined whether pharmacist involvement could reduce medication errors in veterinary settings. In September 2022, the hospital introduced daily pharmacist chart reviews in its small animal intensive care and intermediate care units. Over the following 6 months, researchers observed a decrease in medication-related incident reports, from 62% of all incidents before implementation to 48% afterward. While the change was not statistically significant, the downward trend points to the potential benefits of clinical pharmacist oversight in veterinary care.
Chart reviews were conducted Monday through Friday and included cross-checking automated dispensing cabinet transactions against patient charts and medication administration records. Notably, during this same period, incident reports related to other types of errors, such as communication or system-related issues, increased, suggesting that the drop in medication-related reports was not part of a broader decline.
Why dosing errors are so common
The predominance of dosing errors was likely due to a combination of operational and system-level challenges. These included calculation mistakes related to patient weight, lack of pharmacist review prior to medication access, and a high volume of medications being dispensed during busy clinical hours. In some cases, errors occurred when medications were pulled from dispensing cabinets without a second check, particularly after hours when pharmacy staff was unavailable.
Veterinary hospitals often operate without the integrated systems and checks that are standard in human health care. The researchers noted that many veterinary settings still rely on paper records and nonintegrated dispensing systems, which can make it difficult to catch errors before they reach the patient. In addition, many medications involved in the reported errors—such as methadone and butorphanol—are commonly used for chemical restraint or anesthesia, procedures that carry higher inherent risk.
Limitations and future directions
The study was conducted at a single veterinary teaching hospital, the Oregon State University Veterinary Teaching Hospital in Corvallis, OR, which may limit the generalizability of its findings to other institutions or private practices. Additionally, pharmacist chart reviews did not occur on weekends or holidays, and the 6-month post-implementation period was relatively short compared to the nearly 4 years of preintervention data. These factors may have affected the ability to detect statistically significant changes in error rates.
The authors also noted that the study did not account for potential confounding variables or include a cost-effectiveness analysis of pharmacist involvement. Broader studies across multiple veterinary settings, both academic and private, could help validate the findings and explore whether similar trends hold in different environments.
Future research may also assess how technology integration, staff training, and standardized documentation practices contribute to medication safety in veterinary care. ■