PSA Advisories

Update on Medication Errors Associated with Incorrect Patient Weights

Healthcare practitioners require a current, accurate patient weight because weight is often used to determine an appropriate medication dose. When errors occur during the process of obtaining, documenting, and communicating and using a patient’s weight, the dose of a medication can be dangerously incorrect. Analysts reviewed event reports relating to patient weight submitted to the Pennsylvania Patient Safety Authority through the Pennsylvania Patient Safety Reporting System from December 2008 through November 2015. Of the 1,291 event reports related to patient weights, the majority of errors reached the patient (74.8%, n = 966) and the most common factors involved were documented weight too high (23.8%, n = 307), confusion between pounds and kilograms (23.2%, n = 300), and documented weight too low (14.9%, n = 192). Important risk-reduction strategies include obtaining a current, accurate weight instead of relying on a historical, stated, or estimated weight; and obtaining, documenting, and communicating patient weights in metric units only (i.e., grams or kilograms). (Pa Patient Saf Advis 2016 Jun;13[2]:50-57.)

Please click here for the complete article on the Pennsylvania Patient Safety Authority’s website.

More Alerts

Medication use in the perioperative setting presents unique patient safety challenges compared with other hospital settings. For example, perioperative medication prescribing and administration often bypasses standard safety checks, such as electronic physician order entry with decision support,