Introduction

Veterinarians have an important relationship of trust with their clients because they are privy to clients’ confidential emotional and economic information. Consequently, clients are important stakeholders within the veterinary profession.¹ Previous reports suggest that veterinarians’ perceptions of their clients’ needs and expectations, with respect to veterinary health care, may differ from what clients actually need or expect when they present their animals. Understanding how unmet client expectations may have an adverse effect on veterinarians’ interactions with their clients is important for successful veterinary practice.²

Veterinary clinical services should aim to provide high-quality, ethically justified, and proficient service to animals and their owners. Given the devotion of many pet owners to their pets, predicted or unexpected treatment failure is a basis for mistrust in the proficiency of the treating veterinarian. Clients undertake legal action, such as a professional negligence or veterinary malpractice case, if they believe that a veterinarian has failed to adequately explain the medical and surgical aspects of animal care. Alternatively, clients may complain to the relevant veterinary medical board, which may investigate the veterinarian’s behavior. The 4 elements of a claim of typical malpractice case are duty, violation, proximate cause, and damages.³ The number of veterinary malpractice law suits and verdicts to financially compensate owners for financial and emotional damage has reportedly increased.^4,5 The number of owners’ complaints and subsequent inquiries of case outcomes is anticipated to rise.⁶

A medical error (ME) in a veterinary practice has been described as an error or omission leading to a less than ideal or potentially adverse outcome for a patient.⁷ Because reporting mechanisms are lacking, it is difficult to determine the extent of MEs in veterinary practices.⁸ While the majority of MEs do not lead to an apparent adverse effect, a significant number of human patients suffer permanent injury or death from MEs every year.⁹ Whether this fact is also true in veterinary medicine is not known. The majority of reported MEs have been classified under the headings of clinical errors (errors made in the diagnosis, the treatment process, or drug administration and professional negligence), errors due to lack of communication (unprofessional veterinary behavior), and management errors (lack of follow-up care, lost samples, and high veterinary costs).^1,6,10

Several studies have reported on the impact of MEs in veterinary medicine,^7,8,10–12 including specific issues such as surgical and anesthetic errors in small animal cases.^13–15 A limited number of studies have reported on pet owners’ allegations in veterinary medicine.^1–3 For instance, 1 study¹ reported on the development of a coding framework through a thematic analysis of 1,218 complaints made to the Veterinary Council of New Zealand during 1992 to 2016. Technical competency (62%) and professional behavior (32%) were identified as the 2 key themes of the complaints. The study’s subthematic analysis highlighted service standards, high-quality care, honesty and trustworthiness, and client-veterinarian communication.¹ There is a common reluctance to admit and discuss MEs in veterinary medicine.¹¹

In Türkiye, animal owners can submit verbal or written notifications and complaints to the Turkish Veterinary Medical Association (TVMA) based on Article 121 of the Implementation Regulation of Law No. 6343.¹⁶ After making the necessary evaluations, the TVMA notifies the necessary complaint file to the relevant Chambers of Veterinarians Board. The Chambers of Veterinarians Board reviews all relevant documentation from the owner and veterinarian before deciding whether the owner’s claim is justified. The Court of Honor decides in accordance with the “Disciplinary Offenses and Penalties” in the 10th section of the relevant regulation. Disciplinary penalties in Article 116 of this section may include (1) a written warning, (2) a fine with the amounts specified in the law, or (3) a temporary suspension of professional licenses for a period of 15 days to 6 months.

To the best of the authors’ knowledge, pet owners’ complaints filed to the TVMA have not been analyzed in Türkiye. The objective of this study was to investigate the complaint claims against veterinary practices over a 10-year period (2012 to 2021) and to determine what issues veterinarians could improve to reduce the number of MEs. Veterinarians may acquire an awareness toward MEs by analyzing and considering, creating safer working procedures, expanding knowledge, and being more observant. It is hoped that this study will encourage debate within veterinary practices about ways to lower the number of MEs given the detrimental effects that MEs can have on veterinarians as well as the animals involved.

Methods

Descriptive analysis of complaints data

Data were taken from the original TVMA complaint forms completed by pet owners, as well as email exchanges. Of the 158 written complaint files referred to the TVMA against veterinarians between January 2012 and December 2021, 127 (80%) were reviewed and subjected to a descriptive analysis. Due to inadequate data given by the complainants, the residual 31 (20%) complaint files were not evaluated. The data for each complaint included the name of the veterinarian and address of the veterinary clinic, personal data and gender of the owner, species and breed of the animal, detailed complaint text, and date of treatment.

Files were retrospectively evaluated by use of a complaint taxonomy previously described,^1,6 resulting in 296 complaint issues. We devised an unvalidated thematic complaint-coding system based in part on a previous study¹⁷ from the human medical field. Briefly, the complaint issues of each case were determined to belong to 1 of 3 primary themes, including clinical, management, or relationship. Within each theme, cases were subsequently determined to belong to 1 of a set of secondary or tertiary themes. Finally, the issues within each tertiary theme were further labeled with the coding that most precisely described the character of the complaint (Figures 1 and 2; Supplementary Table S1).

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Primary, secondary, and tertiary themes identified from 127 complaints lodged by pet owners against veterinarians between 2012 and 2021.

Citation: Journal of the American Veterinary Medical Association 262, 9; 10.2460/javma.23.10.0586

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Summary of the primary complaint theme by animal species.

Citation: Journal of the American Veterinary Medical Association 262, 9; 10.2460/javma.23.10.0586

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The severity of harm sustained by the animals caused by MEs was assessed with an unvalidated approach based on a previously reported scale.¹² The severity of the harm was graded with a 3-item scale as temporary harm (grade 1), permanent harm (grade 2), and death (grade 3; Table 1).

Table 1

Distribution of the severity of harm caused by medical errors, by animal species, filed by the Turkish Veterinary Medical Association.

Harm severity	Total n/total (%)	Cat n/total (%)	Dog n/total (%)	Othera n/total (%)	P values
Temporary harm	15/91 (16.5)	10/15 (66.7)	5/15 (33.3)	0/15 (0)	χ2 = 1.502
					P = .447
Permanent harm	7/91 (7.7)	5/7 (71.4)	2/7 (28.6)	0/7 (0)	χ2 = .928
					P = .634
Death	69/91 (75.8)	32/69 (46.4)	32/69 (46.4)	5/69 (7.2)	χ2 = 3.332
					P = .193
Total	91/91 (100)	47/91 (51.6)	39/91 (42.9)	5/91 (5.5)

^aOther included the following pets: budgerigar, cockatiel, hamster, parrot, and pigeon.

Results

A total of 296 separate incidents were extracted from the data, with most of the 127 complaining pet owners experiencing > 1 negative issue (Supplementary Table S1). About 76% (97/127) of the filed complaints were by a female and about 24% (30/127) by a male pet owner.

The animal type that was the object of the complaint was identified in 296 cases and included dogs (150/296 [51%]) and cats (133/296 [45%]), while budgerigars, cockatiels (Nymphicus hollandicus), hamsters, parrots, and pigeons were incidentally involved (4%; Supplementary Table S1). The distribution of complaints per service type was 77% for general, often single-handed veterinary practices; 15% for veterinary services in a municipal animal shelter; 5% for animal hospitals; and 3% for others (including referral clinics and pet shops).

The complaint issues were assigned to the clinical theme (62%), management theme (24%), and veterinarian–pet owner or relationship theme (14%; Figure 2; Supplementary Table S1). The negative experiences mainly concerned errors made in the diagnosis-treatment chain and associated adverse events. There was no statistically significant association between the combined 3 complaint themes and the affected pet species (P = .873).

Within the clinical theme, 69% of the complaints were MEs and 31% were concerned with insufficient care or neglect. Within the MEs, errors were made with treatment (44%), with the diagnostic process (34%), in surgical procedures (12%), with drug prescription (6%), and with anesthesia (3%; Figure 3). The clinical theme was not associated with pet species (P = .706; Supplementary Table S1).

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Summary description of the types of medical errors by animal species.

Citation: Journal of the American Veterinary Medical Association 262, 9; 10.2460/javma.23.10.0586

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Two examples of supporting pet owners’ comments for complaints within the clinical theme are given here: “The veterinarian prescribed a total of 3 (2 of which were antibiotics) drugs for my cat, who had a fever at 40 °C. Although the veterinarian diagnosed a urinary tract infection according to the results obtained from the test he performed,” according to another veterinarian to whom the owner had taken the cat, “there was no such thing. The drugs caused my cat to suffer for a week and nearly [die]. This person misdiagnosed and prescribed the wrong drugs.” In addition, regarding insufficient care or neglect, an owner expressed that the veterinarian caused the death of her cat as a result of negligence, as proven by the audio and video recording of the veterinary clinic: “When I went to the clinic, I saw my cat being put in another cat’s box and lying on its feces. An intravenous catheter was not placed [in] my cat, no food was given, no serum was given; moreover, nothing was done for any treatment.”

The impact of the ME was assessed by evaluating the severity of harm inflicted on the pet. Ninety-one animals suffered treatment-related harm. Mortality was the end result in the majority (76%) of these cases, and in 8% the error had resulted in permanent harm. In 17% of cases, the harm was temporary. No significant association was found between the severity of damage by an ME and the affected pet species (P = .362; Table 1).

The most common complaint in the management theme was violation of the legislation (51%). Regarding violation of the legislation, 1 owner complained that treatment had been undertaken by a technician without their consent: “Instead of a veterinarian, […] a technician performed the examination, diagnosis, and treatment of my dog.” Another owner stated the provision of an adequate on-hours service to be important in municipal shelters: “[The veterinarian] was not at the shelter in on-hours, so I could only reach him at a coffee shop or at home.” This was followed by issues about poor sanitation (31%) and unexpectedly high invoices (17%). One pet owner reported that her 11-month-old cat died as a result of a defect in sanitation after an operation: “[The veterinarian] did not use gloves, follow hygiene rules, or maintain a sterile environment during the operation. The cages of hospitalized animals were dirty, there were empty syringes around the cage, the same patient diaper was used for more than 1 animal, and the surgical instruments were sterilized in an ordinary home oven, not a sterilizer.”

Complaints about fees arose in the context of serious complications or fatalities that the veterinarian had not predicted:

The veterinarian came and did the clinical and ultrasound examinations on our cat. Then the veterinarian insisted on using a high dose of corticosteroids for the cat, who already had the very late stage of kidney failure due to [feline infectious peritonitis (FIP)]. When I strongly objected, he said that there was a 100 euro medicine abroad and that he could be brought for FIP. As if this malicious and wrong diagnosis (absence of FIP was proven by PCR test) weren’t enough, the veterinarian charged me an exorbitant fee of 2.000 Turkish liras (TL) that included the veterinarian’s examination fee of 1.500 TL and for routine drug administration procedures of 500 TL. This is not so important when it comes to the life, but how ethical is it to take advantage of emotional weaknesses and turn them into material things?

The variable pet species was significantly associated with perceived poor management (P = .047). For instance, perceived high invoices/bills were significantly associated with cats. Cat owners complained more about violation of legislation (33%) by the attending veterinarian than about high bills. Dog owners seemed more concerned about sanitation and, like the cat owners, high invoices (Supplementary Table S1).

The complaints in the relationship theme were dominated by lack of communication (69%) and poor information (31%). Complaints related to the relationship theme were not associated with pet species (Supplementary Table S1). Pet owners expected the veterinarian to avoid rude, threatening, or disrespectful behaviors. Examples of complaint comments about the relationship secondary themes are given here:

After our cat fell down from the sixth floor, we immediately called our veterinarian, but she did not pick up the phone. When we called later, we could not reach her in any way. However, we were able to reach the staff at the clinic and we wanted them to reach the veterinarian as well. We had to wait 2 hours for the veterinarian to arrive. When the veterinarian came, we complained to her about the issue and the answers she gave us: “We were just asleep,” and “did [you] drop your cat from the sixth floor?” and “If you hadn’t dropped it.” After this situation and a long discussion, she removed the serum from the injured cat and said, “Take away your cat from here,” and kicked us out of the clinic.

The veterinarians were expected to be sensitive to pet owners’ informational and emotional needs, respond quickly to their questions or concerns, and maintain regular contact:

The veterinarian said, “Let your dog be my guest for 2 days, I will call you and give you information.” Since the veterinarian did not call after 2 days, I called and asked about the condition of the dog. He did not give any information about my dog’s illness and hung up saying that he will be my guest on Sunday. On Monday, when I went to the clinic to see the dog’s condition, the veterinarian said, “I didn’t call you because your dog disappeared yesterday.” When I asked how it disappeared, and why didn’t you call and inform me, he said that “I left the dog in the garden. Then, I took care of a sick cat inside, and when I came out after 5 minutes, the dog was not in the garden; I looked for but could not find it.

Discussion

To the best of the authors’ knowledge, this study was the first to report on complaints against veterinarians dealing with pet animals in Türkiye. The majority (69%) of complaints within the clinical theme contained MEs for cases filed with the TVMA. Medical errors most commonly (44%) occurred with treatments, while mortality was the end result in the majority (76%) of those cases. Violation of the legislation was most common (51%) in the management theme. The complaints in the relationship theme were dominated (69%) by lack of communication. Given that MEs accounted for the majority of pet owners’ complaints in our study, veterinarians would be wise to assess how well they are maintaining and improving their professional knowledge and competence.

We found that in Türkiye most complaints about pet treatment were by female pet owners, in keeping with previous studies.^19,20 The reason may be that women have a stronger bond with their pets than men.^21–23 We found that the majority of complaints involved medical issues, although management and relationship aspects should not be ignored completely. In Turkish veterinary practice, complaints about clinical issues were roughly 3 times more common than those about management. Our study showed the need for improving clinical proficiency and communication skills of veterinarians active in the clinical field. Pet owners expect to be supported by their veterinarian to make informed decisions.¹ By understanding the client’s level of knowledge, relevant information should be tailored and clients should be taught about their options to aid in decision-making.²⁴

Preventing errors starts with knowing them. It was reported that the most frequent MEs were those made with treatment (23%), diagnosis (18%), and surgery (16%),⁷ in keeping with our findings. Examples of treatment errors include wrong indication of a drug, wrong dose, wrong dosing interval, wrong route of application, wrong case treated, and drug allergy.^10,12,15

Our findings showed an apparently high incidence of harm caused due to MEs in comparison with previous studies beyond Türkiye.^6,10,12 This may be due to lack of peer support in a single-handed veterinary practice. There are few animal hospitals in Türkiye with substantial staff and equipment that may help to reduce the risk of MEs. Moreover, hospital staff generally have individuals experienced in coaching younger colleagues, diagnostic methods, case safety, drug safety, animal care, and case management. Similar to previous reports,^7,10,13 we identified failed surgery procedures as a significant cause of complaints. In this respect, the use of surgical checklists for cats and dogs would reduce the incidence and severity of postoperative problems.^13,25

Our study showed a weakness of pet owners in compliance with and knowledge of the relevant laws and high cost of services of small animal practice, resulting in owners feeling overcharged by veterinarians. Another weakness was a lack of transparency in the costs and treatment fees requested by veterinarians. In accord with our results, perceived overcharging for services has been reported in other countries in relation to small animal medicine.^1,26–28 Regarding the cost of veterinary services, dog owners complained about 3 times less than cat owners, which is similar to a previous study.²⁹ Furthermore, a survey in New Zealand showed that cost was one of the main reasons for cat owners to refrain from professional veterinary care.³⁰ Finally, the perceived problems with sanitation by dog owners was a worrying finding, indicating a severe omission of basic veterinary care and damaging the reputation of the veterinary profession.

In most North Atlantic countries, complaints of inappropriate veterinary professional behavior, lack of proficiency, and illegal actions are subject to client rights and/or laws dealing with protecting and safeguarding the public or animals’ health, or both. Processes vary for handling filed complaints. However, both private veterinary practitioners and state veterinary medical boards can be involved in processing complaints, disciplinary committees, and disciplinary hearings. In many European countries, practicing veterinarians must be a member of a veterinary college or chamber; in others, the state appoints veterinary and legal professionals as members of disciplinary committees. For example, in the UK, practitioners must adhere to the Royal College of Veterinary Surgeons code of professional conduct.³¹ However, organizations with less legal authority influence the standard of professional veterinary service by codes of conduct (ie, the European Veterinary Code of Conduct). This provides a set of standards that specifies veterinary ethics and principles of professional conduct that all veterinarians should follow and that supports disciplinary committees.³² In the US, state veterinary licensing boards are tasked with protecting the public by regulating the practice of veterinary medicine, whereas professional associations promote the profession. Veterinary licensing boards review complaints related to services of veterinarians or veterinary technicians and the behavior related to the practice of veterinary medicine. The boards will take action to discipline the licensee if they find evidence that proves the licensee was incompetent, provided unprofessional services, or engaged in unethical, unprofessional, or illegal behavior.³³ These sanctions may include fines, probation, continuing education requirements, suspension of licensure, or other actions the board sees fit.³

Similar to Türkiye, pets in most of the states of the US are considered as property, the true value of which may be restored upon settling malpractice cases.⁴ In cases of negligence resulting in fatal outcome or permanent injury, the treating veterinarian may be sentenced to reimburse the pet’s monetary value. Although the owners may never be satisfied with the reimbursement, the pet’s monetary value may cover investments in the animal, such as vaccination, neutering, and training, as well as the costs of purchasing a new animal.³⁴ Similar to the rules applied in the US, Turkish laws also consider animals as property. As in many countries mentioned above, if a legally forbidden act was committed, veterinarians may face criminal sanctions ranging from fines to imprisonment according to the Turkish Penal Code.³⁵ Based on the Implementation Regulation of the Law No. 6343, a veterinarian who shows no interest or carelessness toward the animal and the owner, makes diagnosis and treatment contrary to the general medical rules, does not keep the records required by the legislation, and does not use proper prescriptions and documents may face condemnation and administrative fines.¹⁶ In the event that the prescribed disciplinary punishments are finalized, if the action constitutes a crime under the Turkish Penal Code, a criminal complaint must be filed by the TVMA to the Public Prosecutor’s Office. Thus, understanding veterinary legislation and veterinarians’ legal rights and obligations can help veterinarians defend themselves from pet owners’ claims.

The present study’s content-analysis component showed that many of the complaints were underpinned by poor client-veterinarian communication. Pet owners consider some veterinarians to be very poor in client communication, to be unempathetic, and to show rude and threatening behaviors; all are disrespectful. Previous studies have reported that veterinarians who have good client relations and communication skills have a beneficial impact on client satisfaction and adherence.^36–39 Our study provided some evidence for the significance of verbal expressions of empathy during companion animal consultation. It is critical to show empathy to the client directly throughout the veterinary consultation because this may promote client satisfaction.^38,40 For this reason, educational processes regarding professional communication and behavior should be structured at both the undergraduate and postgraduate levels.

The Federation of Veterinarians of Europe (FVE) serves as an umbrella organization for veterinary associations in 39 European nations (not only EU member nations). The FVE closely follows societal concerns and expectations, and when faced with technical or ethical dilemmas, careful considerations and balances are made in the interests of animals, owners, the environment, and society at large. The FVE aims to ensure that every veterinarian may carry out their professional responsibilities independently, without any excessive pressure.⁴¹ According to the FVE Code of Good Veterinary Practice,⁴² pet owners should be informed about the risks and possible side effects of used medicinal products, as well as about the benefits and costs of the prescriptions. Good clinical practice also includes control and nonuse of expired vaccines and drugs as well as correct storage. Adhering to these standards will reduce pet owners’ complaints caused by drug errors. Therefore, veterinarians should be familiar with these codes.

Our study had several limitations. Our data were not based on an exact representation of Türkiye as a whole; rather, they only represented complaints filed with the TVMA. Complaints made to local chambers of veterinarians in Türkiye were not included in our study. The complaint taxonomy only represented the domains and categories of pet owners’ complaints within the study, and there could have been other unidentified categories. Some owners perceived the routine examination and treatment costs to be high, and these became the subject of complaints.

In summary, the complaints have shown some of the common MEs made by veterinarians. The results represent the main shortcomings felt strongly enough by pet owners to file a formal complaint. The veterinary profession in Türkiye should develop strategies to reduce the frequency of MEs and ensure that lessons are learned from them. Further study will concentrate on how this affects the curriculum for veterinary undergraduate training and professional growth of veterinarians who are currently practicing in Türkiye. It is suggested that an awareness of the number of common MEs should be spread among Turkish veterinarians to reduce negligence and malpractice. Furthermore, animal owners are more likely to be happier when veterinarians provide good communication and record all necessary documents for any veterinary medical malpractice or complaint.

Supplementary Materials

Supplementary materials are posted online at the journal website: avmajournals.avma.org.

Disclosures

The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.

Funding

The authors have nothing to disclose.