The potential contribution of deficiencies in handoffs between anaesthetists to the fatal outcome following ventral slot surgery in a dog.

Increasingly complex cases in veterinary anaesthesia challenge anaesthetists, especially when patient care is transferred (handed off) between team members. Standardized and structured patient handoffs are used in human medicine to improve patient safety. A male neutered Dachshund, aged 9 years, with a history of cervical pain presented for magnetic resonance imaging. The medical history included mitral valve insufficiency (grade B1) and intra-anaesthetic bradycardia and apnoea at a different clinic. Induction of anaesthesia was performed by a fourth year anaesthesia resident and the dog handed off to a veterinary nurse (nurse 1) during the magnetic resonance imaging scan. The dog was hypotensive for approximately 40 minutes during the scan. Following a decision to perform ventral slot surgery, nurse 1 accompanied the dog to theatre. Throughout anaesthesia, the dog was mechanically ventilated. During surgery, anaesthesia care of the dog was handed off to a less experienced veterinary nurse (nurse 2) who was unaware of the previous hypotension and heart disease. During handoff to a senior veterinary anaesthetist (supervisor) for recovery, who was also unaware of the episode of hypotension and heart disease, nurse 2 stated that after initial apparent spontaneous ventilation was observed, following weaning from the ventilator, the dog had become apnoeic during transport. The duration of apnoea was approximately 1 minute. No heartbeat was palpable and an agonal breath was observed. Cardiopulmonary resuscitation was started, with return of spontaneous circulation after 15 minutes. Although the dog swallowed, and displayed palpebral and pupillary reflexes, spontaneous breathing never resumed. After 20 hours of mechanical ventilation, the dog was euthanized. A range of factors contributed to deficiencies in case management, including incomplete information transfer during handoffs and anaesthetist training. This case resulted in raised awareness of patient handoffs as an important event and development of a handoff checklist for use at our institution.