Pa Patient Saf Advis 2018 Sep;15(3).
Safety Stories: A Weighty Problem
Anesthesiology, Critical Care, Emergency Medicine, Nursing, Pediatrics
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​This vignette presents a brief, timely highlight of events reported through the Pennsylvania Patient Safety Reporting System (PA-PSRS) that may provide a learning opportunity for facilities.

A Weighty Problem

Events*

Reviewing patient's profile and found her weight entered as 73 lb. Patient reweighed and weight is 73 kg [161 lb].

Weight of 8.8 kg written on the order sheet. Orders for medications for intubation based on weight of 8.8 kg. Actual weight is 4 kg [8.8 lb]. Patient's vital signs remained stable during intubation.

Patient weighed during preoperative assessment, weight charted as 13.2 kg. Pt to OR. During procedure, physician's assistant recalled patient weight as 6 kg at the last office visit. After procedure, patient weighed and weight documented at 6.2 kg. Weight was done in kg [during preoperative assessment]; family had requested weight in pounds and pound weight was documented as kg weight.

Opportunity

Errors involving documentation that confuse kilograms (kg) and pounds (lb) are particularly hazardous for pediatric patients—whose medications or other treatments are usually adjusted according to the patient's weight—but may also have consequences for adult patients.1 In the first case, the patient's weight was obtained in kilograms but incorrectly documented in pounds. In the second case, the patient's weight in pounds was incorrectly documented as kilograms and he received a medication overdose.

Because of the magnitude of the difference between weights in pounds and in kilograms (1 kg = 2.2 lb), the error is often identified by astute clinicians who recognize the difference between the documented weight and their knowledge of the individual patient. However, relying on clinician vigilance is an insufficient strategy.

The Pennsylvania Patient Safety Authority recently issued recommendations that all patients be weighed and those weights are both obtained and documented in metric units. The recommendations are available through the Pennsylvania Bulletin.2

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* The details of the PA-PSRS event narratives in this article have been modified to preserve confidentiality.

Notes

  1. Update on medication errors associated with incorrect patient weights. Pa Patient Saf Advis. 2016 Jun;13(2):50-7. http://patientsafety.pa.gov/ADVISORIES/Pages/201606_50.aspx 
  2. Final recommendation to ensure accurate patient weights, 48 Pa. Bull. 5679 (2018 Sep 8). Also available: https://www.pabulletin.com/secure/data/vol48/48-36/1430.html.
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