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. [ABSTRACT FROM AUTHOR]