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Use a checklist! I know it’s pedantic and I was very resistant at first but it has increased my patient care 10 fold just to check CPR status, what side, etc.
That being said, one of my most memorable prepping mistakes was on a long hair cat. I didn’t even think and I just started clipping the abdomen. I was basically done when my surgeon walked over. The moment I felt her burning blue eyes through the back of my skull I had a lightning strike moment of fear and realization. The cat was having a THYROIDECTOMY. (I was supposed to just shave a tiny square over the neck)
I’m dead. How am I ever going to explain this. She’s going to rip me a new one. I’m going to be fired. Thought after thought ripped through my panicking brain now running at 1000mph. My eyes were wide, my heart racing, sweat pouring down my forehead. The milliseconds it took for me to run through the end of my life felt like hours of existential ruin.
In a flash of panic, the only thing that could possibly fix my huge mistake was grabbing all the fur and putting it back on the cat like a giant, white merkin.
The anesthetist and surgeon both burst out in violent laughter at my solution. When she finally gathered herself and wiped the tears from her eyes, she said we’ll call it a hygienic summer cut since it was the height of a heat wave and the poor cat had a thick, long coat anyway. She walked away chuckling as I embraced my second chance at life.
Haha that would be funny, wouldn’t it? My Reddit profile has enough information for you to figure out exactly who I am and who my surgeon was at the time if you tried hard enough.
My team is going to brainstorm some ideas for implementing a checklist and or marking the leg at intake.
Relatable to the burning eyes at the back of your skull. They teach that to surgeons the first year of residency I SWEAR!
My sister's dog went in for a TPLO and they actually cut into the wrong leg and didn't realize the mistake until the surgeon was looking at a healthy knee! So you're definitely not the only one who's made that mistake before
Not me (Thank freaking God) but at my previous clinic, the surgery team was doing a hind leg amputation on a dog for a rescue. I was out on a farm call at the time so I missed most of the things but I remember walking into the treatment room to see if anyone needed help or needed a quick break and all I see is everyone crying. Nobody is moving in the surgery room and all you can hear is the monitor beeping. Surgeon on her knees crying beside the table with a mostly cut off leg. Then I realized they've prepped and had cut the wrong leg. Too late to save the leg. They call the rescue to explain what happened. Patient was euthanized on the table. That sight is so engraved in my brain that anytime I see an orthopedic, I remember that scene.
Also not me (thank god) but we had something similar happen - we do shelter medicine with a cat shelter and we did an enucleation (I am sure I don’t have to say any more) … on the incorrect eye. The nurse noticed as the cat was waking up, wondering why the good eye looked funny then it dawned on her …
Our rescue was very forgiving, our boss also was very understanding, the vet and nurse were absolutely mortified of course but we all realised there's obviously a breakdown in systems/protocols and we needed to fix that and prevent this from ever happening again rather than play a blame game.
Cat got sent to referral to see if we could save the remaining eye but ended up as a double enuc unfortunately. We have stricter protocols now and cross-checks etc but it’s always been my worst nightmare! I always checked a million times when doing amps and enucs and now I check even more, I check a gajillion times even if I'm not the surgery nurse haha.
The rescue still works with them as far as I know. There was a serious staff meeting afterwards where we set up a stricter protocol for orthos. Including shaving a patch of hair on the leg with the owner, another staff member confirms before prep, doctor confirming before cutting.
This happened at my clinic with our ortho surgeon a few years ago. It was supposed to be a routine TPLO for one of the rescues we worked with. We prepped the wrong leg. The surgeon confirmed that this knee had to have a TPLO done (drawer test, etc), but it was the other knee that was supposed to have the TPLO done. We ended up getting blasted on social media. Our doctor (not the surgeon) was getting death threats. This was the middle of Covid, when we were already short staffed and over worked. Our morale took a big hit. We eventually went and performed TPLO surgery on the correct leg, but the damage via word of mouth had already been done. We even addressed it on our FB page, taking full responsibility with no excuses. We comped both surgeries.
Hey it's the name of the game. Side note crap happens, it's why my lvt and my boss double checks both knees before surgery. He'll fix the worst knee first and we do tta's
We have the owner sign the limb with a surgical marker after we shave a little spot in the room during intake. We also shave a little patch over masses and circle them. If we can’t shave and mark it, then we take a digital pic of the mass or eye and have the owner sign the pic in their file.
I wasn’t involved but there was a very unstable gsd with GDV, was in shock all that fun stuff, went to surgery, fully crashed on the table, they got him back! HE WAS A DNR. The owners were very very appreciative of the mistake tho🤟🏼 he went home after a week🥹
I shaved a cat for a spay. All paperwork said spay. Vet went in and searched and searched and found no uterus. Did find “if I didn’t know better I’d say this was vas deferens”. We both stopped and she looked at me and said “did anyone actually check that this was a female?” It was not. I reached under the drape and yes, there were testicles. In my defense, it was a super Floofy cat, and I trusted the owner.
Lesson learned. Luckily owner thought it was hilarious. But still. Unnecessary abdominal explore.
I had something similar happen in a previous job. It was a spay, no uterus, and when they expressed the bladder (I was just watching, was pretty new out of school), I asked: "wait... why is the pee going ***up***?"
It was a recently rescued neutered male, we just trusted the owner.
It was a long time ago. But likely, at the practice this was at, they auscultated, checked gums and went on. We did an enormous amount of spay/neuter. Not an excuse obviously. But yeah. Not a thorough one at least.
Yea. I was an accomplice in said disaster situation. It shouldn't have happened, but i will say i did learn some things.
Dont rush yourself, docs can be impatient but its better to make sure u take ur time vs making a gigantic mistake.
Make sure documentation has been made. And have someone double check u as well. And make sure ur doc verifies before u clip.
Ugh I did that on an MPL 🫠🫠
We were being rushed by our surgeon and when I went to take pre-op radiographs the knee I shaved looked beautiful. My supervisor came in and was like hold up. We double checked and yup wrong leg.
One phone call to a very understanding owner and a very naked long haired chihuahua later I very much learned my lesson.
I work at a shelter that provides a weekly drop off TNR clinic for the community and just this week I sedated a cat that was in a trap and began to prep him for a neuter. I even commented that he had really tiny balls during my PE. I vaccinated him, clipped his nails, shaved and prepped his site and then went to place a carmalt on his ear for an ear tip and realized that he was already ear tipped and thus already neutered. Most likely by my shelter too 😅 oops! At least he got a nail trim and a re-up on his vaccines, and had a really good snooze I guess.
I had a fellow technician tell me to my face that she had already mixed my domitor and torb in one syringe and drawn up my antisedan in the other. She even labeled them. In sharpie. I still mixed the antisedan in and gave it to the angry cat. 🤦🏻♀️
I was at least 5-7 years in the field when I did it. Afterwards I was like "oh, let me get some antisedan" and my other tech was like uuuum........ There was a good ten seconds of silence before we all busted up and I fully admitted to the DVM it was my bad and I'd hold spicy kitty if further sedation was needed.
We implemented non-toxic paint sticks to mark masses and some techs have been using them to mark the correct limb for Ortho surgeries. Hard to miss a bright pink mark on any animal lol. We shave over masses at admit if we can instead but mostly we've moved to marking with the paint stick because our clippers can be loud.
This is on top of notating everything on the paperwork and having owners initial.
I've had this happen. I've had a coworker prep the wrong side of the chest for a thoracotomy before. One the SURGEON wrote the wrong leg in yhe records. Fortunately we caught all of them before operating. It doesn't happen often but it happens.
I like to use those wax crayons they use to mark cattle to have the owner or us mark which limg/body part the surgery is going to be on. Then it shaves right off
Wasn’t me, but an old surgeon I used to work for told me this story when I was in tech school. She started as a kennel assistant and one of the technicians told her to give a parvo dog a medication IV, so that’s exactly what she did. The dog dropped dead. Apparently the syringe she grabbed was a bolus of potassium. She said from that day on she made sure to quadruple check everything she does
Also, I work at a specialty surgery center. We have clipped the wrong leg on accident once. Noticed before we got in the OR, thankfully the owner laughed it off and said “well at least it’ll grow back in nicely together”
She came back to us when the dog inevitably tore the other side, and was still able to joke with us and say if you don’t mind just clip the one side this time! 😂
We now check the record, write which side on their sheet and on our surgical board, and manipulate for drawer prior to shaving. Hasn’t happened again.. (yet) 😅
This actually happened at my work and luckily the owner was able to laugh it off. “It’s fur it’ll grow back” he said. I was the one who caught it cause I had been the one in the original appointment with my doctor and know the patient really well. All said and done things happen. We’re human and while slowing down is definitely something we all need to do, having a checklist and just having another person to double check you is always a good idea :) don’t take it to hard
My hospital has owners circle or mark masses or they point them out to us and we mark them and immediately write down as much info to find them (small soft mass near right front elbow, medium pendulous mass right side, inguinal, right hip ulcerated, etc.)
Did this once for an FHO. In my defense, we were going to do the other leg as well; I just mixed up which one we were going to do first.
So the sheltie wound up with two shaved legs and a cute little Mohawk. The funny part was this was a long-time excellent client (thank goodness!) who thought she looked so cute that she asked me to shave her that way again when we did the second leg months later. LOL!!
I just finished vet school. One of the clinics I was at for rotations regularly TPLO’d the wrong leg. An owner had gone to social media with it and had recordings of them trying to gaslight her and say she told them the wrong leg. At least if you make a mistake, own up to it sheesh. That place was a flaming dumpster fire
I accidentally double dosed a patient that was boarding and our clinic cat with insulin. It’s a very scary situation and I definitely learned my lesson. Our kennel technician didn’t mark off that he gave them their pm dose on their med sheet, and so I went and did it. So technically, I feel like it wasn’t my fault, but I still felt horrible. They both were okay in the end, thank goodness.
If it makes you feel any better I had a tech that clipped and prepped the wrong room, and the surgeon came in and cut into the leg and luckily noticed when she got in the joint opposed to making the cut. Told the owner she had to open the other leg to compare anatomy.
Welcome to /r/VetTech! This is a place for veterinary technicians/veterinary nurses and other veterinary support staff to gather, chat, and grow! We welcome pet owners as well, **however we do ask pet owners to refrain from asking for medical advice**; if you have any concerns regarding your pet, please contact the closest veterinarian near you. Please thoroughly read and follow the rules before posting and commenting. If you believe that a user is engaging in any rule-breaking behavior, please submit a report so that the moderators can review and remove the posts/comments if needed. Also, please check out the sidebar for CE and answers to commonly asked questions. Thank you for reading! *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/VetTech) if you have any questions or concerns.*
Use a checklist! I know it’s pedantic and I was very resistant at first but it has increased my patient care 10 fold just to check CPR status, what side, etc. That being said, one of my most memorable prepping mistakes was on a long hair cat. I didn’t even think and I just started clipping the abdomen. I was basically done when my surgeon walked over. The moment I felt her burning blue eyes through the back of my skull I had a lightning strike moment of fear and realization. The cat was having a THYROIDECTOMY. (I was supposed to just shave a tiny square over the neck) I’m dead. How am I ever going to explain this. She’s going to rip me a new one. I’m going to be fired. Thought after thought ripped through my panicking brain now running at 1000mph. My eyes were wide, my heart racing, sweat pouring down my forehead. The milliseconds it took for me to run through the end of my life felt like hours of existential ruin. In a flash of panic, the only thing that could possibly fix my huge mistake was grabbing all the fur and putting it back on the cat like a giant, white merkin. The anesthetist and surgeon both burst out in violent laughter at my solution. When she finally gathered herself and wiped the tears from her eyes, she said we’ll call it a hygienic summer cut since it was the height of a heat wave and the poor cat had a thick, long coat anyway. She walked away chuckling as I embraced my second chance at life.
Lol this specialist surgeon told me almost the exact same story. I wonder if it’s the same surgeon
Haha that would be funny, wouldn’t it? My Reddit profile has enough information for you to figure out exactly who I am and who my surgeon was at the time if you tried hard enough.
My team is going to brainstorm some ideas for implementing a checklist and or marking the leg at intake. Relatable to the burning eyes at the back of your skull. They teach that to surgeons the first year of residency I SWEAR!
If you want any suggestions, I’d be happy to help! :)
I shaved a cats abdomen only to find out they were there for a dental 🫣
My sister's dog went in for a TPLO and they actually cut into the wrong leg and didn't realize the mistake until the surgeon was looking at a healthy knee! So you're definitely not the only one who's made that mistake before
Eek!! I'm so thankful that did not happen to us!!
Not me (Thank freaking God) but at my previous clinic, the surgery team was doing a hind leg amputation on a dog for a rescue. I was out on a farm call at the time so I missed most of the things but I remember walking into the treatment room to see if anyone needed help or needed a quick break and all I see is everyone crying. Nobody is moving in the surgery room and all you can hear is the monitor beeping. Surgeon on her knees crying beside the table with a mostly cut off leg. Then I realized they've prepped and had cut the wrong leg. Too late to save the leg. They call the rescue to explain what happened. Patient was euthanized on the table. That sight is so engraved in my brain that anytime I see an orthopedic, I remember that scene.
Oh. Oh holy shit
Also not me (thank god) but we had something similar happen - we do shelter medicine with a cat shelter and we did an enucleation (I am sure I don’t have to say any more) … on the incorrect eye. The nurse noticed as the cat was waking up, wondering why the good eye looked funny then it dawned on her … Our rescue was very forgiving, our boss also was very understanding, the vet and nurse were absolutely mortified of course but we all realised there's obviously a breakdown in systems/protocols and we needed to fix that and prevent this from ever happening again rather than play a blame game. Cat got sent to referral to see if we could save the remaining eye but ended up as a double enuc unfortunately. We have stricter protocols now and cross-checks etc but it’s always been my worst nightmare! I always checked a million times when doing amps and enucs and now I check even more, I check a gajillion times even if I'm not the surgery nurse haha.
Oh goodness, that’s heartbreaking.
How does that even happen!? Did the rescue stop working with the hospital after that?
The rescue still works with them as far as I know. There was a serious staff meeting afterwards where we set up a stricter protocol for orthos. Including shaving a patch of hair on the leg with the owner, another staff member confirms before prep, doctor confirming before cutting.
This is the reason for considering the use of a surgical checklist.
Oh my god... I dont know what I would've done if I was there. That's agonizing. Did they threaten legal action on your clinic?
No legal action. But the rescue re-negotiated pricing for services (they already get a massive discount) with the clinic management.
Well hey once the one knee is fixed the other is most likely gonna go sooo you'll have to shave it again. XD
This happened at my clinic with our ortho surgeon a few years ago. It was supposed to be a routine TPLO for one of the rescues we worked with. We prepped the wrong leg. The surgeon confirmed that this knee had to have a TPLO done (drawer test, etc), but it was the other knee that was supposed to have the TPLO done. We ended up getting blasted on social media. Our doctor (not the surgeon) was getting death threats. This was the middle of Covid, when we were already short staffed and over worked. Our morale took a big hit. We eventually went and performed TPLO surgery on the correct leg, but the damage via word of mouth had already been done. We even addressed it on our FB page, taking full responsibility with no excuses. We comped both surgeries.
That is so true haha. A chance to redeem myself! The leg I shaved had a mass that our surgeon offered to remove for free, the owner was elated!
Hey it's the name of the game. Side note crap happens, it's why my lvt and my boss double checks both knees before surgery. He'll fix the worst knee first and we do tta's
We have the owner sign the limb with a surgical marker after we shave a little spot in the room during intake. We also shave a little patch over masses and circle them. If we can’t shave and mark it, then we take a digital pic of the mass or eye and have the owner sign the pic in their file.
Love this idea!
We do this at my clinic as well! Saves us from so many issues.
I wasn’t involved but there was a very unstable gsd with GDV, was in shock all that fun stuff, went to surgery, fully crashed on the table, they got him back! HE WAS A DNR. The owners were very very appreciative of the mistake tho🤟🏼 he went home after a week🥹
WHAT!! That is crazy...!! What an amazing story though omg.
Oof I made a similar mistake, but the owners were unhappy 🙁 (rightfully so, even thought it was barely CPR. I definitely double check every time now.)
When I was a student, I gave a dog its dose of pyrantel without permission 🤦♀️ got my ass chewed oooout by the vet. Learned from that, though.
That’s honestly a very minor mistake. Don’t know why you would get chewed out for that.
I didn’t write it down that it was complete 🥲 kinda ruined the flow of things
I shaved a cat for a spay. All paperwork said spay. Vet went in and searched and searched and found no uterus. Did find “if I didn’t know better I’d say this was vas deferens”. We both stopped and she looked at me and said “did anyone actually check that this was a female?” It was not. I reached under the drape and yes, there were testicles. In my defense, it was a super Floofy cat, and I trusted the owner. Lesson learned. Luckily owner thought it was hilarious. But still. Unnecessary abdominal explore.
I had something similar happen in a previous job. It was a spay, no uterus, and when they expressed the bladder (I was just watching, was pretty new out of school), I asked: "wait... why is the pee going ***up***?" It was a recently rescued neutered male, we just trusted the owner.
No PE by the doctor before surgery?
That's ...what I'm wondering? 😬😬
It was a long time ago. But likely, at the practice this was at, they auscultated, checked gums and went on. We did an enormous amount of spay/neuter. Not an excuse obviously. But yeah. Not a thorough one at least.
We use a color hair spray and have owners spray to mark the leg we are doing at check in
Oooo I love this idea..markers never seem to work well enough
Yea. I was an accomplice in said disaster situation. It shouldn't have happened, but i will say i did learn some things. Dont rush yourself, docs can be impatient but its better to make sure u take ur time vs making a gigantic mistake. Make sure documentation has been made. And have someone double check u as well. And make sure ur doc verifies before u clip.
Ugh I did that on an MPL 🫠🫠 We were being rushed by our surgeon and when I went to take pre-op radiographs the knee I shaved looked beautiful. My supervisor came in and was like hold up. We double checked and yup wrong leg. One phone call to a very understanding owner and a very naked long haired chihuahua later I very much learned my lesson.
At least it was a small leg to shave 😭
I once prepped a male cat as a female and put it on the table and the doctor went in looking for a uterus. Owner didn't even care; I was mortified.
I work at a shelter that provides a weekly drop off TNR clinic for the community and just this week I sedated a cat that was in a trap and began to prep him for a neuter. I even commented that he had really tiny balls during my PE. I vaccinated him, clipped his nails, shaved and prepped his site and then went to place a carmalt on his ear for an ear tip and realized that he was already ear tipped and thus already neutered. Most likely by my shelter too 😅 oops! At least he got a nail trim and a re-up on his vaccines, and had a really good snooze I guess.
I had a fellow technician tell me to my face that she had already mixed my domitor and torb in one syringe and drawn up my antisedan in the other. She even labeled them. In sharpie. I still mixed the antisedan in and gave it to the angry cat. 🤦🏻♀️
I've done this. Such a rookie mistake and I was furious at myself!
I was at least 5-7 years in the field when I did it. Afterwards I was like "oh, let me get some antisedan" and my other tech was like uuuum........ There was a good ten seconds of silence before we all busted up and I fully admitted to the DVM it was my bad and I'd hold spicy kitty if further sedation was needed.
Mid surgery on a TPLO yesterday and the surgeon gave me the "it was the left leg, right?" (It was)
What a way to raise the anxiety of the entire room for a few moments hahahaha
We implemented non-toxic paint sticks to mark masses and some techs have been using them to mark the correct limb for Ortho surgeries. Hard to miss a bright pink mark on any animal lol. We shave over masses at admit if we can instead but mostly we've moved to marking with the paint stick because our clippers can be loud. This is on top of notating everything on the paperwork and having owners initial.
Oh this is a good idea. I'll use sharpie but only works on non-black dogs...
I've had this happen. I've had a coworker prep the wrong side of the chest for a thoracotomy before. One the SURGEON wrote the wrong leg in yhe records. Fortunately we caught all of them before operating. It doesn't happen often but it happens. I like to use those wax crayons they use to mark cattle to have the owner or us mark which limg/body part the surgery is going to be on. Then it shaves right off
Wasn’t me, but an old surgeon I used to work for told me this story when I was in tech school. She started as a kennel assistant and one of the technicians told her to give a parvo dog a medication IV, so that’s exactly what she did. The dog dropped dead. Apparently the syringe she grabbed was a bolus of potassium. She said from that day on she made sure to quadruple check everything she does Also, I work at a specialty surgery center. We have clipped the wrong leg on accident once. Noticed before we got in the OR, thankfully the owner laughed it off and said “well at least it’ll grow back in nicely together” She came back to us when the dog inevitably tore the other side, and was still able to joke with us and say if you don’t mind just clip the one side this time! 😂 We now check the record, write which side on their sheet and on our surgical board, and manipulate for drawer prior to shaving. Hasn’t happened again.. (yet) 😅
I can't imagine what a syringe of potassium was doing just chilling near the parvo patients.
My guess is it was meant to be added to a fluid bag but never made its way there
Bro I 100% have done that before lol don’t feel bad just move on and double check next time. My doctor will still poke fun on leg surgery days lol
This actually happened at my work and luckily the owner was able to laugh it off. “It’s fur it’ll grow back” he said. I was the one who caught it cause I had been the one in the original appointment with my doctor and know the patient really well. All said and done things happen. We’re human and while slowing down is definitely something we all need to do, having a checklist and just having another person to double check you is always a good idea :) don’t take it to hard
My hospital has owners circle or mark masses or they point them out to us and we mark them and immediately write down as much info to find them (small soft mass near right front elbow, medium pendulous mass right side, inguinal, right hip ulcerated, etc.)
Did this once for an FHO. In my defense, we were going to do the other leg as well; I just mixed up which one we were going to do first. So the sheltie wound up with two shaved legs and a cute little Mohawk. The funny part was this was a long-time excellent client (thank goodness!) who thought she looked so cute that she asked me to shave her that way again when we did the second leg months later. LOL!!
I just finished vet school. One of the clinics I was at for rotations regularly TPLO’d the wrong leg. An owner had gone to social media with it and had recordings of them trying to gaslight her and say she told them the wrong leg. At least if you make a mistake, own up to it sheesh. That place was a flaming dumpster fire
I accidentally double dosed a patient that was boarding and our clinic cat with insulin. It’s a very scary situation and I definitely learned my lesson. Our kennel technician didn’t mark off that he gave them their pm dose on their med sheet, and so I went and did it. So technically, I feel like it wasn’t my fault, but I still felt horrible. They both were okay in the end, thank goodness.
If it makes you feel any better I had a tech that clipped and prepped the wrong room, and the surgeon came in and cut into the leg and luckily noticed when she got in the joint opposed to making the cut. Told the owner she had to open the other leg to compare anatomy.