Accidental ketamine administration in a horse supposed to undergo general anaesthesia for tenovaginoscopy: Errors and the need of Morbidity and Mortality Rounds in veterinary medicine

An 11-year-old, 500 kg, healthy mare was admitted for tenovaginoscopy. A jugular venous catheter was inserted to administer detomidine for diagnostic imaging and for anaesthesia-related drug administration. The horse was premedicated with intramuscular acepromazine and intravenous flunixin. For sedation, 7.5 mL of a solution, presumed to be xylazine 2%, was drawn up in a syringe and labelled with a sticker. Two minutes after injection of 7.5 mL from xylazine-labelled syringe, the horse showed severe ataxia and fell. Nystagmus and catatonia appeared while one person sat on its neck, to prevent it from rising. After 8 minutes, the horse could not be kept down and took several uncoordinated attempts to stand, still showing nystagmus and ataxia for several minutes. The xylazine-labelled syringes were analysed. They contained pure ketamine. This case report should raise awareness about clinical errors, a healthy error culture and use of Morbidity and Mortality Rounds to improve patient and personnel care.