Case report details inadvertent epidural cefazolin injection in dog: full analysis
A case report published online January 26, 2026, in the Journal of Veterinary Emergency and Critical Care details an unusual medication error with a surprisingly benign outcome: inadvertent epidural injection of cefazolin in a dog. The dog, a 5-year-old neutered male mixed-breed weighing 37.2 kg, had been anesthetized for routine lateral suture cranial cruciate ligament repair when 800 mg of cefazolin, totaling 8 mL, was mistakenly administered into the epidural space. After referral to The Ohio State University Veterinary Medical Center, the dog recovered uneventfully, remained hemodynamically stable, showed no seizure activity, and was discharged the following day. The authors say this appears to be the first veterinary report of this specific error. (pubmed.ncbi.nlm.nih.gov)
The report lands in a clinical area where medication mix-ups are a known risk. Cefazolin is a standard perioperative antibiotic in small animal practice and is commonly used for orthopedic surgical prophylaxis in dogs at about 20 to 22 mg/kg IV before incision, with repeat dosing during longer procedures. Because it’s routine, familiar, and often prepared during the same perioperative window as sedatives, induction agents, and epidural drugs, it can become part of a crowded, interruption-prone workflow. A 2024 literature review on medication errors in veterinary anesthesia concluded that these errors are among the most commonly reported medical errors in veterinary medicine, with distraction, fatigue, workload, supervision gaps, dose calculations, and preparing multiple syringes in a short time frame all contributing to risk. (ohiostate.pressbooks.pub)
What makes the case notable is not just the error, but the outcome. The dog had no immediate adverse neurologic effects and no seizures, despite prior literature suggesting cefazolin can be epileptogenic when introduced into the central nervous system. That concern is grounded in earlier veterinary literature: a 2014 JVECC case report described status epilepticus in a dog after inadvertent intrathecal cefazolin injection during myelography. The distinction between intrathecal and epidural exposure matters clinically, and this newer case suggests the consequences may not be uniform across wrong-route events, even with the same drug. Still, a single uncomplicated case shouldn’t be read as evidence that epidural cefazolin is safe. (pubmed.ncbi.nlm.nih.gov)
The authors frame the event as a patient-safety lesson as much as a neurologic one. Federal regulators have long warned that veterinary medication errors can arise from look-alike or sound-alike products, transcription mistakes, and decimal-point or dosing errors. In anesthesia settings, published prevention strategies include clearer labeling, standardized preparation steps, communication safeguards, and organizational or engineering controls to reduce wrong-drug and wrong-route administration. This case adds a concrete example from everyday companion animal surgery, where a familiar antibiotic became the wrong drug in the wrong space. (fda.gov)
There wasn’t much public expert commentary specific to this paper, but the surrounding literature points in a consistent direction: vigilance in the peri-anesthetic period matters as much as technical skill. Ohio State’s own anesthesiology service highlights epidural analgesia as part of advanced perioperative care, underscoring that these procedures are routine enough to be normalized in referral settings. At the same time, AAHA’s anesthesia and monitoring guidelines stress that recovery is a high-risk period and that patients should be monitored closely by trained personnel until physiologic parameters normalize and the patient is alert and ambulatory. That recommendation fits the management described in this case, where overnight observation followed an initially stable recovery. (vmc.vet.osu.edu)
Why it matters: For veterinary professionals, the main takeaway isn’t that inadvertent epidural cefazolin is harmless. It’s that common drugs in common workflows can still produce rare, high-consequence errors, and that outcome may depend on route, dose, timing, and rapid recognition. In general practice and specialty surgery alike, cefazolin is ubiquitous in orthopedic cases, making segregation from epidural medications, immediate syringe labeling, read-back or two-person verification, and structured handoffs especially relevant. The case also reinforces the value of escalation and monitoring after a wrong-route event, even when the patient initially appears stable. (ohiostate.pressbooks.pub)
What to watch: The next question is whether this remains an isolated case report or prompts broader discussion in anesthesia and ECC circles about wrong-route event reporting, standardized epidural medication workflows, and whether specialty groups develop more explicit safeguards for antibiotic handling in the perioperative setting. (sciencedirect.com)