R E V I E W S & A N A LY S E S Update on Medication Errors Associated with Incorrect Patient Weights Bryan R. Bailey, PharmD, BCPS INTRODUCTION Patient Safety Analyst Healthcare practitioner access to key patient information is an essential element of the Michael J. Gaunt, PharmD Sr. Medication Safety Analyst medication use process.1 Key patient information used to guide appropriate medication Matthew Grissinger, RPh, FISMP, FASCP therapy includes age, weight, height, allergies, diagnoses, laboratory values, and vital Manager, Medication Safety Analysis signs.1 A 1995 study indicated that inadequate availability of patient information dur- Pennsylvania Patient Safety Authority ing medication prescribing, dispensing, and administration was associated with nearly one-fifth (18%) of identified errors.2 Determining the appropriate dose of many medications requires an accurate patient ABSTRACT weight. Numerous medications are dosed on units of weight (e.g., mg/kg, mcg/kg/min). Healthcare practitioners require a cur- Other medications are dosed by body surface area (BSA; e.g., mg/m2), which incorpo- rent, accurate patient weight because rates a patient’s weight. Additionally, various medications require dosage adjustments weight is often used to determine an based on renal function, using creatinine clearance (CrCl) as determined by a formula appropriate medication dose. When (e.g., the Cockcroft-Gault formula) that requires an accurate patient weight.3 A missing errors occur during the process of or inaccurate patient weight can cause a prescribed medication dose to be significantly obtaining, documenting, and communi- different from the appropriate dose and negatively impact patient outcome.3-5 cating and using a patient’s weight, the A previous review of events reported to the Pennsylvania Patient Safety Authority dose of a medication can be danger- through its Pennsylvania Patient Safety Reporting System (PA-PSRS) identified a variety ously incorrect. Analysts reviewed event of problems related to obtaining and documenting accurate patient weights.6 A 2014 reports relating to patient weight submit- ECRI Institute report on weight-based medication dosing errors reported to the ECRI ted to the Pennsylvania Patient Safety Patient Safety Organization (PSO) from September 2012 through August 2013 indi- Authority through the Pennsylvania cates that organizations continue to struggle with obtaining and documenting accurate Patient Safety Reporting System from patient weights.7 It appears that medication errors related to the process of obtaining December 2008 through November and documenting patient weight continue in spite of recommendations from multiple 2015. Of the 1,291 event reports organizations designed to reduce errors associated with patient weight.8-13 As such, related to patient weights, the majority analysis was performed on weight-related events reported to the Authority since its of errors reached the patient (74.8%, 2009 analysis. n = 966) and the most common fac- tors involved were documented weight too high (23.8%, n = 307), confusion METHODS between pounds and kilograms (23.2%, Analysts reviewing events reported to the Authority through PA-PSRS can classify n = 300), and documented weight too reports using a monitor code for future query opportunities. Analysts searched the low (14.9%, n = 192). Important risk- PA-PSRS database for reports of medication errors tagged as weight-related, and reduction strategies include obtaining a “Other” event type reports that were weight related, submitted to the Authority from current, accurate weight instead of rely- December 2008 through November 2015. These queries yielded 1,167 and 154 reports, ing on a historical, stated, or estimated respectively, for a sum of 1,321 reports. weight; and obtaining, documenting, The medication name, patient care area, event type, event description, and harm score, and communicating patient weights adapted from the National Coordinating Council for Medication Error Reporting and in metric units only (i.e., grams or Prevention (NCC MERP) harm index,14 were provided by the reporting facility. When kilograms). (Pa Patient Saf Advis 2016 a medication name data field was left blank or incomplete but the name was provided Jun;13[2]:50-57.) in the event description, an analyst adjusted the medication name field. Reports were Corresponding Author evaluated to first verify that the event was related to patient weight and then determine Matthew Grissinger what factors were associated with the event. Reports were categorized into type of error (e.g., confusion between pound [lb] and kilogram [kg], incorrect estimated weight) based on analysis of the event description. Analysts could assign multiple types of error for each report, based on the event description. Analysts identified reports involving high-alert medications, based on the ISMP List of High-Alert Medications in Acute Care Settings.15 Roughly 3% (n = 30) of the reports were excluded from final analysis because they had been submitted more than once (n = 7) or the event was not related to patient weight (n = 23). Consequently, 1,291 event reports were included in the final analysis. Page 50 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority RESULTS Figure 1. Harm Scores for Events involving Incorrect Patient Weights, as reported to the Pennsylvania Patient Safety Authority, December 2008 through November Based on harm score, almost three-fourths 2015 (N = 1,291) (74.8%, n = 966) of events reached the patient (harm score = C through I) and NUMBER OF REPORTS 0.9% (n = 11) resulted in patient harm 559, (harm score E through I; see Figure 1). 600 43.3% Reports of events that did Almost one-third (30.7%, n = 396) of not reach the patient events required patient monitoring or 500 (25.2%, n = 325) 396, intervention to preclude harm (harm 30.7% score D). A majority (8 of 11) of the 400 Reports of events that events with patient harm involved high- 262, reached the patient alert medications. 300 20.3% (74.8%, n = 966) Emergency departments (EDs; 29.4%, n = 379) were the most frequently 200 involved care area. When totaled, a 52, variety of intensive care units (ICUs) 100 4.0% 11, 7, 2, 0, 1, 1, comprised 15.9% (n = 205) of care areas 0.9% 0.5% 0.2% 0.0% 0.1% 0.1% involved. Figure 2 shows the most com- 0 A B1 B2 C D E F G H I MS16420 monly reported specific patient-care areas, encompassing 65% (n = 839) of events. HARM SCORE More than one-quarter of events involved pediatric patients (age younger than 18 Figure 2. Care Areas Most Commonly Reported in Events Involving Incorrect Patient years; 26.3%, n = 340) and 38% (n = 490) Weights, as reported to the Pennsylvania Patient Safety Authority, December 2008 of events involved elderly patients (65 through November 2015 (N = 1,291) years of age or older). However, only 1 of the 11 harm events (9.1%) involved a CARE AREA pediatric patient. Emergency 379, Figure 3 shows the medications most department 29.4% commonly reported to be involved in Medical/ 99, 7.7% the events. The top 10 medications were surgical unit involved in 63.7% (n = 823) of event Pharmacy 62, 4.8% reports. Two anticoagulants, heparin (29.7%, n = 383) and enoxaparin (8.6%, Telemetry 59, 4.6% n = 111), were involved in almost two- Medical/ 48, 3.7% fifths (38.3%, n = 494) of events. In the surgical ICU entire dataset, more than half (59.3%, Pediatric unit 43, 3.3% n = 765) of the events involved a high- Med/surg/ 39, 3.0% alert medication. The specific medication pediatric unit involved could not be determined in Medical unit 32, 2.5% nearly 10% (9.6%, n = 124) of reports. When evaluating event types as reported Cardiac 28, 2.2% intermediate unit by facilities, the five most common event Med/surg/ 25, 1.9% types accounted for 94.4% (n = 1,219) of card ICU the events (see Table). Wrong dose/over 25, 1.9% Cardiac unit dosage events represented the most com- monly reported event type, comprising 0 50 100 150 200 250 300 350 400 MS16421 42.2% (n = 545) of all reports. NUMBER OF REPORTS Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 51 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Figure 3. Most Common Medications involved in Events related to Incorrect Patient were found in more than 60% (n = 799) Weights, as reported to the Pennsylvania Patient Safety Authority, December 2008 of event reports. Analysts were unable to through November 2015 (N = 1,291) determine a contributing factor in 18.5% MEDICATION (n = 239) of events. The following are examples of events in 383, Heparin* which the documented weight was too 29.7% high.* Enoxaparin* 111, 8.6% A premature infant was ordered 1mEq/kg of potassium chloride as Vancomycin 76, 5.9% a replacement dose for a K [potas- Acetaminophen 61, 4.7% sium] value of 2.5. Patient’s weight is 0.58 kg. The nurse incorrectly Ibuprofen 39, 3.0% changed the dosing weight from 0.58 to 6 kg [increasing the documented Propofol* 37, 2.9% weight by a factor of 10]. Within the same minute, she realized the error Gentamicin 34, 2.6% and changed the weight back [to the correct value]. Pharmacy dispensed Hydration† 32, 2.5% the medication (14.4 mL or 6 mEq) based on the [incorrect weight value DOPamine* 30, 2.3% (approximately a 10-fold error)] and the medication was administered. Milrinone* 20, 1.5% A double check was completed 0 prior to administration. During the 50 100 150 200 250 300 350 400 administration, the patient developed MS16422 NUMBER OF REPORTS bradycardia and was successfully resuscitated. Potassium chloride * High-alert medication administration was stopped dur- † Represents intravenous replacement and maintenance fluids (e.g., lactated Ringer, normal saline, dextrose with saline solutions) ing resuscitation. Later in the day, pharmacy discovered that the dose sent was based on a 6 kg weight that Table. Medication Error Event Types Associated with Events Involving Incorrect Patient was in their EMR [electronic medical Weights, as Reported to the Pennsylvania Patient Safety Authority, December 2008 through record] system. November 2015 (N = 1,291) A patient was dosed milrinone based EVENT TYPE NO. OF REPORTS %* on an incorrect weight of 400 kg. The Wrong dose/over dosage 545 42.2 patient’s actual weight is 114 kg. The patient subsequently developed short Other 223 17.3 runs of ventricular tachycardia and Wrong dose/under dosage 215 16.7 hypotension. He became symptom- Wrong rate (intravenous) 182 14.1 atic with complaints of fatigue and lightheadedness. The milrinone was Monitoring error 54 4.2 stopped and the patient was treated All other event types 72 5.6 with norepinephrine and stabilized. * Total is greater than 100% because of rounding A pediatric patient was written an order for fentaNYL 1 mcg/kg/dose. Analysis revealed several factors, or types of documented weight too high (23.8%, errors, associated with medication errors n = 307), confusion between pounds and * The details of the PA-PSRS event narratives involving patient weight (see Figure 4). The kilograms (23.2%, n = 300), and docu- in this article have been modified to preserve three most commonly identified factors, mented weight too low (14.9%, n = 192) confidentiality. Page 52 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority Figure 4. Types of Error involving Incorrect Patient Weights, as identified in Reports Submitted to the Pennsylvania Patient Safety Authority, December 2008 through November 2015 (N = 1,291)* NUMBER OF REPORTS 350 307, 300, 23.8% 23.2% 300 239, 250 18.5% 192, 200 14.9% 150 87, 100 6.7% 55, 4.3% 50 26, 20, 27, 18, 18, 2.1% 2.0% 1.5% 11, 1.4% 1.4% 0.9% 0 n† ed w ht ed ig t/ r er fu o h ted d n W actu etwe wei eal ei ted ro lo we gh ig an ee th n gh Un g ad t we ht ht us us er gh ow k we al id on to en y w jus O d ei o g lb tw i or ht to n an n h kn C ht um tu en be tio ed ig ht e we re e la bl ig c at ng al b en ig tu we we Do od sio cu la M nd bet tim we ’s ra et ai ac al nt es pe b av d up C tie te m up d b ct ix- ht en pa an up a rre te ix- ig M m ix- M we co cu In ro Do o N MS16423 TYPES OF ERROR * Analysts could classify a given report under multiple error types. Percentages are based on total number of reports. † The report did not have enough information to determine the error type. Patient’s weight entered incorrectly The following are examples of events 9 mg as calculated by pharmacy and in electronic health record as 67 kg. in which there was confusion between started the drip of 81 mg over 1 hour. The patient weighs 5.6 kg. Dose pounds and kilograms. Approximately 50 minutes into the was ordered by anesthesia as 67 mcg The physician placed the patient’s infusion of the drip, it was noted that instead of 5.6 mcg. FentaNYL given weight into the record but placed the weight was incorrect and the bolus in OR [operating room] (dose not the pounds in as kilograms (i.e., was stopped. The patient was given recorded). The surgeon reported child 160 pounds was input as 160 kg). approximately 72 mg of the drip. had bronchospasms and desaturations Pharmacy mixed the [alteplase] dose According to pharmacy, the patient during OR case. Pharmacy saw this according to the weight. The nurses should have been dosed with a bolus order in PACU [postanesthesia care verified the dose off the incorrect of 6.5 mg and a drip of 58.9 mg. unit] and halted immediately. weight and administered the bolus of The patient received an overdose of Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 53 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S approximately 15.6 mg. The patient dosing regimen, but patient was also The admission weight entered in subsequently hemorrhaged and on cefTRIAXone and azithromycin the chart was 63 kg, which is listed required intubation and chest tube and doses were adjusted for the cor- as an “estimated weight.” When insertion for hemothorax. rect weight. Patient has had negative a heparin drip was ordered for the Patient triaged in ED via EMS blood cultures to date and antibiotics patient, the order automatically [emergency medical services] following were increased as preventive measure. pulled in the admission weight. This witnessed generalized seizure at home. Patient weighed 62 kg in ED. A was not the patient’s actual weight. Patient has history of seizures and heparin drip was initiated in ED On subsequent days when the patient has been treated with phenobarbital using this weight. Patient was was actually weighed, her weight was 30 mg PO BID [orally, twice a day] at received to floor with heparin drip found to be significantly lower at home. Patient’s weight obtained in tri- infusing. Patient was weighed via bed 58 kg. Since heparin is dosed by age and recorded in EMR as 55.7 kg, scale, which was zeroed out prior to weight, the patient was receiving however patient’s actual weight is use. Patient weighed at 72.2 kg a higher dose of heparin than she 55.7 lb (25.3 kg). The initial (10 kg difference). Patient was receiv- required. I noticed this error after the PHENobarbital level was less than ing wrong dose because of wrong patient’s a PTT was supratherapeutic 2.1 [mcg/mL, normal therapeutic weight. The nurse weighed patient on two consecutive days. This error range: 15 to 40 mcg/mL], therefore on bathroom style scale twice in could have been avoided if the patient a loading dose of 20 mg/kg was pre- ED. Both times, she obtained same was actually weighed on admission. scribed to be administered over weight of 62 kg and dosed heparin An [adult patient] was admitted 30 minutes. Actual dose administered accordingly. Later the nurse learned of with nausea, vomiting, chest pain, was 1,100 mg but based on correct discrepancy in weight from floor nurse, anxiousness, and DKA [diabetic weight the dose should have been so she weighed herself and found scale ketoacidosis] (BG [blood glucose] 505 mg. After the loading dose infu- [ED bathroom style scale] to be off 484 mg/dL). In the ED, an insulin sion, patient became lethargic and by 10 kg. The scale was placed out of bolus of 10 units (regular) and infu- difficult to arouse and anesthesiology service until battery changed. sion at 10 units/hr was ordered. The and neurology were consulted. A Another significant factor identified in patient only had an estimated weight repeat phenobarbital level was over event reports was the incorrect estima- in the ED of 85 kg. An actual weight 50 [mcg/mL]. The patient was intu- tion of patient weight (6.7%, n = 87; see performed once patient arrived to bated, ventilated, and transferred to Figure 4). Healthcare practitioners most ICU a few hours later was 66 kg. tertiary care facility. frequently performed incorrect estimation The patient’s BGs dropped precipi- The following are examples of reports in of patient weight, but incorrect weight tously to 146 mg/dL and the insulin which the documented weight was too low. estimates were also provided by patients, infusion was turned off. The patient family members, and guardians. Besides needed the insulin infusion placed The patient weighs 108 kg and was back on later that morning, due to on a heparin drip with dose at the event reports clearly associated with incorrect estimated weights, many of the an increased anion gap. The initial 18 units/kg/hr. The IV [intravenous] error in weight may have contributed pump was programmed with weight events related to too high or too low docu- mented weights were likely related to the to a rate that caused the precipitous of 1.08 kg. The patient’s aPTT level [drop] that led to infusion stopped was subtherapeutic. practice of estimating weights. Fifty-four percent (n = 47 of 87) of the incorrect prematurely. Patient’s weight on acute care floor estimated weight events provided enough Examples of less frequently identified today of 39.8 kg, triple checked and information to calculate a percent differ- factors (see Figure 4) or multiple factors compared to ED weight of 21.7 kg. ence between estimated and actual weight. identified in one event report follow. The discrepancy was reported to the Of these 47 events, the estimated weight senior resident. Patient’s mom states Received patient from ED with was wrong by more than 10% in 80.9% norepinephrine and DOBUTamine patient was weighed on a bed in the (n = 38 of 47) events. The percent of error ED and that she (mom) commented infusing through peripheral lines ranged from 6% to 75%; in one such at too high of an hourly rate. The that the weight of 21.7 kg didn’t seem case, this represented a 58 kg (32.8%) accurate in the ED, but the 21.7 kg weight had been entered as 240 kg underestimation of the patient’s weight. on the pump. When receiving report was still documented. Patient’s pain Examples of these reports follow. medications were based on home from ED, the nurse had stated the Page 54 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority estimated weight of the patient was pharmacist updated the weight that accurate patient weight, they face 240 lb. The patient has red track- populates into [the pharmacy infor- obstacles related to documenting and ing from peripheral IV site where mation system] with the patient’s communicating the weight to other mem- DOBUTamine was infusing. new and accurate weight. The new bers of the healthcare team. Clinicians Patient’s weight was accidentally weights in [electronic health record] must take the obtained weight value and entered into dose field by pharmacist. do not populate to [pharmacy infor- accurately transfer this information to Patient received 72 units/kg/hr of mation system], thus any dosing based the medical record, either paper based heparin instead of 12 units/kg/hr, on weight may be incorrect. or electronic, and to an infusion pump which exceeded the maximum rate. or other systems requiring this informa- Patient received more than 5,000 DISCUSSION tion. This is a process ripe for error as units of heparin over an hour instead demonstrated by many events (23.2%, Similar to the previously published of the ordered 1,000 units. For n = 300) involving confusion between Advisory article6 and ECRI Institute unknown reasons, the pharmacist pounds and kilograms. A clinician may report,7 data analysis revealed general overrode a dose alert warning. The obtain a weight measured in pounds and themes related to errors involving patient nurse attempted to use the drug library forget to convert to kilograms, or obtain weight. These themes revolve around to program the pump but received a weight in kilograms but document it (1) obtaining a current, accurate patient an alert and programmed the pump incorrectly as pounds. Additionally, clini- weight; (2) documenting and communi- manually. CT [computed tomography] cians may transcribe the weight into the cating the weight value; and (3) properly [scan] of head showed no evidence of medical record or infusion pump incor- using the weight value. Event reports acute intracranial pathology. rectly, by transposing numbers or using exposed the complexity and error-prone Clinical oncology specialist noticed the wrong patient’s weight. nature of obtaining, documenting, com- weight was significantly different municating, and using patient weights. Similar to the issue described by Hilmer between flow sheet and medication and colleagues,3 certain event reports Numerous difficulties in obtaining a cur- order. The specialist used kg weight pointed to problems related to the patient rent, accurate patient weight exist.6 For to dose chemotherapy order and did weight being documented in multiple example, many critically ill patients are not notice conversion was incorrect locations within the medical record. This not weighed in EDs and ICUs because by 10 kg. The weight difference was may lead to the documentation of multi- of the urgency of their clinical status.5,16,17 not noticed by anyone prior to patient ple different values in the medical record, Healthcare facilities may not possess the receiving chemotherapy. The patient causing confusion among clinicians about equipment necessary (e.g., standing scales, received one dose of chemotherapy and which value is current and correct. Also, pediatric scales, wheelchairs scales, bed was scheduled for next cycle on a later depending on the location in the record scales) to facilitate the accurate collection date. Upon further investigation, it where the weight is documented, some of patient weights.16,17 Even if present, was noted that weight was recorded in clinicians (e.g., pharmacists) may not be the equipment may not be functional or pounds with an incorrectly calculated able access or view the weight value. This reliable.18 These barriers may lead clini- kilogram weight next to it. problem is exacerbated by the numer- cians to forego weighing a patient and The patient was given acyclovir ous clinical systems into which a weight decide to use a previously documented based on her real body weight. Per the should or must be documented. For weight or estimate a patient’s weight.5,16,17,19 infectious disease team, the acyclovir example, patient weight may be required Abundant literature exists highlighting the should have been prescribed based on in the medical record, computerized inaccuracies of clinicians and patients/ the patient’s ideal body weight. The prescriber order entry (CPOE) system, caregivers estimating patient weights and patient developed renal failure as a pharmacy information system, infusion its association with medication errors, result of the incorrect doses. pump, and other systems as appropri- adverse events, and clinical ineffective- A heparin drip was ordered at ate. These systems may not be integrated ness.5,6,11,16 Our analysis revealed ample 18 units/kg/hour. [Pharmacy] or automatically share patient weight evidence that Pennsylvania healthcare dosing weight was 82 kg which = information, resulting in the possibility practitioners experience and encounter 1,476 units/hr = 14.8 mL/hr. Patient’s of multiple different weight values being many of these same barriers to obtaining a actual weight was 68 kg =1,224 units/hr documented across systems. current, accurate patient weight. = 12.2 mL/hr. Shortly after the order Although many medications dosed by Once clinicians overcome the barriers was verified, the nurse called the weight use a patient’s actual weight, in associated with obtaining a current, pharmacy with a new weight. The some situations it is more appropriate to Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 55 ©2016 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S use a patient’s ideal body weight (IBW), reduce risk of errors in the medication- in which weight fluctuations are adjusted body weight (ABW), or another use process involving patient weight. expected, or situations in which a determined weight value to serve as the Strategies related to patient weight that weight variation may impact the “dosing weight.”20,21 Patients can receive healthcare facilities can apply to the medi- course of care.6,12,23,24 inappropriate dosages of medications cation-use process include the following: —— Document patient weight in a promi- when the actual body weight is used as —— Ensure all patient care areas have nent location within the medical the dosing weight instead of the more the necessary equipment to easily record readily viewable by all health- appropriate IBW or ABW, or vice versa. obtain an accurate patient weight, care practitioners.8,9,12 In nearly 3% (n = 38) of event reports, including weights for infants and —— Develop organizational medication- these mix-ups were identified as a factor children, as appropriate. Examples use policies that state weight-based contributing to the event. of possible equipment include floor medications will not be prescribed, Perhaps more significant is the risk of scales, stretchers and beds with built- dispensed, or administered unless an perpetuating the use of an inaccurately in scales, and standing, chair, and accurate weight is available (except in obtained or documented patient weight wheelchair scales.4,6-9,12,22,23 emergencies).6 throughout the episode of care.19,22,23 —— To facilitate accurate weight mea- —— Implement “hard stops” or auto- Fuller and colleagues found that nearly surements, use and maintain (e.g., mated clinical decision support at 80% of patients given vancomycin (a med- test, calibrate) scales in accordance the time of data entry to alert clini- ication that should be dosed by weight) with applicable manufacturer cians when the weight parameter is in the ED and subsequently admitted recommendations.18,24 missing (for weight-based medica- to the hospital received an unchanged, —— Weigh each patient as soon as pos- tions) or when the entered patient inappropriate dose.19 Although the ben- sible on admission and during each weight value is not consistent with efits of electronic health records (EHRs) outpatient or ED encounter, exclud- an expected value.6,7,22,23 are numerous, Bokser describes the ing encounters in which medications —— Develop organizational policies that dangers associated with EHRs and the are not prescribed (e.g., laboratory clearly define specific criteria for perpetuation of bad data and subsequent visit). Avoid the use of an estimated, when medications will be dosed by erroneous decision support.22 historical, or stated weight.6,7,10-13 other than actual body weight (e.g., —— Measure patient weight in metric IBW, ABW) and delineate where Limitations units only (i.e., grams or kilograms). and how this “dosing weight” will be In-depth analysis by the Authority of Use scales that measure in metric communicated to clinicians to pre- medication errors involving patient weight units only, or lock scales to measure vent confusion and error.17 occurring in Pennsylvania facilities is lim- only in metric units.7-10,12,13,22,23 —— Maximize available device integration ited by the information reported through to enable automatic, accurate, and —— Document and communicate patient PA-PSRS, including the error description transparent transmission of patient weight in metric units only. Ensure and reasons why the event occurred. weight data directly from scales to computer information system Additional patient weight events and EHRs, pharmacy information sys- screens, infusion pumps, and other associated causes may have been reported tems, and medical devices.22 medication device screens, printouts, but not identified by the query and analy- and preprinted order forms prompt sis. Additionally, unique organizational CONCLUSION users to record patient weight in reporting cultures and patterns, along metric units only.7,10,12,13,22,23 Healthcare practitioners need current, with different interpretations of what —— Develop organizational expectations accurate patient information, includ- occurrences are reportable may lead to that obtaining the patient’s actual ing patient weight, to properly guide reporting variations. weight is part of the mandatory medication therapy. Analysis of 1,291 nursing assessment and reweighing reports submitted to the Authority from RISK REDUCTION STRATEGIES of the patient occurs as warranted, December 2008 through November 2015 The events included in this analysis, based on patient’s clinical condition. revealed multiple factors contributing to observations from the Institute for Safe Consider requiring reassessment of medication errors related to obtaining, Medication Practices, and recommenda- a patient’s weight when initiating or documenting, communicating, and using tions in the literature offer strategies changing the dose of weight-based patient weight. Results were consistent that healthcare facilities may consider to medications, clinical situations with those presented in 2009,6 indicating Page 56 Pennsylvania Patient Safety Advisory Vol. 13, No. 2—June 2016 ©2016 Pennsylvania Patient Safety Authority that Pennsylvania facilities continue to Risk-reduction strategies presented in this the occurrence of medication errors struggle with the complexity of the issue. analysis may help organizations minimize involving patient weight. NOTES 1. Cohen MR. Causes of medication errors. 9. American Academy of Pediatrics. Joint 16. Lin BW, Yoshida D, Quinn J, et al. A bet- Chapter 4. In: Cohen MR, ed. Medication policy statement—guidelines for care of ter way to estimate adult patients’ weights. errors. 2nd ed. Washington (DC): Ameri- children in the emergency department. Am J Emerg Med 2009 Nov;27(9):1060-64. can Pharmacists Association; 2007:56. Pediatrics 2009 Oct;124(4):1233-43. 17. Herout PM, Erstad BL. Medication errors 2. Leape LL, Bates DW, Cullen DJ, et al. 10. The Joint Commission. Preventing pedi- involving continuously infused medica- Systems analysis of adverse drug events. atric medication errors [online]. Sentinel tions in a surgical intensive care unit. Crit JAMA 1995 Jul 5;274(1):35-43. Event Alert 2008 Apr 11 [cited 2016 Jan Care Med 2004 Feb;32(2):428-32. 3. Hilmer SN, Rangiah C, Bajorek BV, et 12]. http://www.jointcommission.org/ 18. Byrd J, Langford A, Paden SJ, et al. Scale al. Failure to weigh patients in hospital: a sentinel_event_alert_issue_39_preventing_ consistency study: how accurate are medication safety risk. Intern Med J 2007 pediatric_medication_errors/ inpatient hospital scales? Nursing 2011 Sep;37(9):647-50. 11. Michaels AD, Spinler SA, Leeper B, et al. Nov;41(11):21-24. 4. Greene S, Dargan P, Shin GY, et al. Medication errors in acute cardiovascular 19. Fuller BM, Mohr N, Skrupky L, et al. Doctors and nurses estimation of the and stroke patients: a scientific statement Emergency department vancomycin use: weight of patients: a preventable source from the American Heart Association. dosing practices and associated outcomes. of systematic error. J Toxicol Clin Toxicol Circulation 2010 Apr;121(14):1664-82. J Emerg Med 2013 May;44(5):910-18. 2004;42(5):611-15. 12. Emergency Nurses Association. Position 20. Ginzburg R, Barr WB, Harris M, et 5. Barrow T, Khan M, Halse O, et al. Esti- statement: weighing patients in kilograms al. Effect of a weight-based prescribing mating weight of patients with acute [online]. 2012 Mar [cited 2016 Jan 13]. method within an electronic health stroke when dosing for thrombolysis. https://www.ena.org/practice-research/ record on prescribing errors. Am J Health- Stroke 2016 Jan;47(1);228-31. Practice/Position/Pages/Weighing- Syst Pharm 2009 Nov 15;66(22):2037-41. PtsinKG.aspx 6. Pennsylvania Patient Safety Authority. 21. Pai MP. Drug dosing based on weight and Medication errors: significance of accu- 13. Institute for Safe Medication Practices. body surface area: mathematical assump- rate patient weights: Pa Patient Saf Advis 2016-2017 targeted medication safety best tions and limitations in obese adults. 2009 Mar [cited 2016 Jan 12]. http:// practices for hospitals [online]. 2015 Dec Pharmacotherapy 2012 Sep;32(9):856-68. patientsafetyauthority.org/ADVISORIES/ [cited 2016 Jan 15]. http://www.ismp.org/ 22. Bokser SJ. A weighty mistake [online]. AdvisoryLibrary/2009/Mar6(1)/ tools/bestpractices/TMSBP-for-Hospitals. WebM&M 2013 Mar [cited 2016 Jan 11]. Pages/10.aspx pdf https://psnet.ahrq.gov/webmm/case/293 7. ECRI Institute. Medication safety: inac- 14. National Coordinating Council for Medi- 23. Paparella, S. Weighing in on medication curate patient weight can cause dosing cation Error Reporting and Prevention. safety. J Emerg Nurs 2009 Nov;35(6):553- errors [online]. 2014 Feb [cited 2016 Jan NCC MERP index for categorizing medi- 55. 15]. https://www.ecri.org/components/ cation errors [online]. 2001 Feb [cited 2016 Jan 11]. http://www.nccmerp.org/ 24. Tipton PH, Aigner MJ, Finto D, et al. PSOCore/Pages/PSONav0214.aspx?tab=1 Consider the accuracy of height and types-medication-errors 8. Emergency Nurses Association. Position weight measurements. Nursing 2012 statement: weighing pediatric patients in 15. Institute for Safe Medication Practices. May;42(5):50-52. kilograms [online]. 2012 Mar [cited 2016 ISMP list of high-alert medications in Jan 5]. https://www.ena.org/practice- acute care settings [online]. 2014 [cited research/Practice/Position/Pages/ 2016 Jan 11]. http://www.ismp.org/ WeighingPedsPtsInKilo.aspx Tools/institutionalhighAlert.asp Vol. 13, No. 2—June 2016 Pennsylvania Patient Safety Advisory Page 57 ©2016 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 13, No. 2—June 2016. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority. Copyright 2016 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to http://visitor.constantcontact.com/ d.jsp?m=1103390819542&p=oi. To see other articles or issues of the Advisory, visit our website at http://www.patientsafetyauthority.org. Click on “Patient Safety Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Pennsylvania Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (Mcare) Act. Consistent with Act 13, ECRI Institute, as contractor for the Authority, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the Pennsylvania Patient Safety Authority, see the Authority’s website at http://www.patientsafetyauthority.org. An Independent Agency of the Commonwealth of Pennsylvania ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 50 years, ECRI Institute marries experience and indepen- dence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions. Scan this code with your mobile device’s QR reader to subscribe to receive the Advisory for free.