Weighty Errors

According to a report from the Institute of Medicine of the National Academies, medication errors are among the most common medical errors, harming at least 1.5 million people every year. The extra medical costs of treating drug-related injuries occurring in hospitals alone conservatively amount to $3.5 billion a year, and this estimate does not take into account lost wages and  productivity or additional health care costs. A report from the Pennsylvania Patient Safety Authority (April 2009) identified the most common specific medication errors associated with incorrect weights. These include overdosage errors (43%), underdosage errors (21%) and incorrect intravenous rate calculations (10%). These findings were based on 479 sentinel events reported between June 2004 and November 2008. They specifically document medication errors resulting from breakdowns in the process of receiving, documenting and communicating patient weights (JC, 2009).

Safely administering medication requires a vast amount of knowledge on behalf of the healthcare professional. It is one of many high risk tasks that can lead to devastating consequences for the patient and for the healthcare professional’s career. Healthcare professionals are responsible for their own actions regardless of a written order from a healthcare provider.

Whenever a medication must be prepared from a dose other than what is ordered, the chance of error increases. Weight based drugs present an additional safety challenge. So how can you help prevent medication errors? The Pennsylvania Patient Safety Authority outlines 5 steps to follow to reduce risk related to inaccurate weights:
1. Get your patient’s exact weight. Emergency room staff should consider including a weight check for all walk-in patients during triage. This can save much time and energy after admission. If a current, accurate weight is not available, find creative ways to measure your patient’s weight, including floor scales to weigh patients and stretchers.
2. Standardize the unit of measure. Weigh all pediatric and adult patients in kilograms at the time of admission or as soon as the patient is stable. According to the Joint Commission, kilograms should be the standard nomenclature for weight on prescriptions, medical records and staff communications.
3. Document weights. Review all locations that may include weight entries, such as printed order forms and infusion pump settings, and ensure that all weight entries are associated with a date field. This will assist other practitioners in recognizing when a weight is outdated. Mandate a weight entry in computerized systems before allowing the system to process orders, and establish a communication process that facilitates the transfer of accurate weight measurements from the nursing staff to pharmacists and physicians. The Joint Commission also proposes the inclusion of maximum and sub-therapeutic dose alerts in the order entry system, based on the patient’s age and weight.
4. Communicate drug orders. Include a provision in your facility’s policies and procedures that weight-based medications are not to be prescribed, dispensed or administered (except in emergencies) unless accurate weight measurements are available. For weight-based therapy, prompts should be included on standard order forms to communicate the patient’s weight.
5. Confirm that the patient’s weight is correct for weight-based dosages and include the weight on each order. The age and weight of a patient can help dispensing professionals double check the dose and route. Prescribers should be encouraged to include the calculated dose and the dosing determination, such as the unit dose per weight to facilitate an independent double-check of a calculation by another healthcare professional.

For more information on safe medication practices, check out RN.com’s course: Medication Safety: Assuring Safe Outcomes or visit The Joint Commission’s 2008 Patient Safety Goals.