Medication errors: significance of accurate patient weights
- Collection:
- Health Policy and Services Research
- Series Title(s):
- Pennsylvania patient safety advisory
- Contributor(s):
- Pennsylvania. Patient Safety Authority. ECRI (Organization) Institute for Safe Medication Practices.
- Publication:
- [Harrisburg, Pa.] : Pennsylvania Patient Safety Authority, c2009
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Body Weight Drug Dosage Calculations Medication Errors -- prevention & control Pharmaceutical Preparations -- administration & dosage Disclosure Documentation Humans United States
- Genre(s):
- Technical Report
- Abstract:
- A patient's weight is important information because it is often used to calculate the appropriate medication dose. When medication errors arise due to inaccurate or unknown patient weights, the dose of a prescribed medication could be significantly different from what is appropriate. Nearly 480 event reports submitted to the Pennsylvania Patient Safety Authority specifically mentioned medication errors that resulted from breakdowns during the process of obtaining, documenting, and/or communicating patient weights. Analysis reveals that 67.2% of the events reached the patient. The unit mentioned most frequently in reports was the emergency department. All the frequently mentioned medications can be dosed based on a patient's weight (i.e., weight-based dosing), and 5 of the top 10 medications are high-alert medications. Breakdowns described in reports most frequently involved failures to obtain accurate patient weight measurements. Once a value was obtained, errors arose from misuse of that value. Examples include problems when patients arrive at a hospital and are not weighed, leading to estimates of patient weights; assumptions that documented weights are current and/or accurate; and documentation breakdowns (e.g., the patient is weighed in pounds, but the weight is erroneously documented as kilograms). Strategies to address these problems include providing all units with the necessary equipment to weigh patients, weighing every patient during triage or admission to facilities, and weighing patients and documenting patient weights only in kilograms.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-DC license. (More information)
- NLM Unique ID:
- 101563443 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101563443