9/10/2018
The Pennsylvania Patient Safety Authority Issues Statewide Recommendation to Ensure Accurate Patient Weights

Harrisburg, Pa., Sept. 10, 2018 – The Pennsylvania Patient Safety Authority (the Authority) issued the "Final Recommendations to Ensure Accurate Patient Weights" in licensed acute care facilities in the Commonwealth.

Patient weight is an essential component to patient information, particularly in regard to the calculation of administered medication dosages (e.g., mg/kg, mcg/kg, mg/m2).

In a 2009 publication, analysis of nearly 480 medication events reported to the Authority named medication errors as a result from breakdowns in the process of obtaining, documenting, and/or communicating patient weights. 

An updated analysis in 2016 further revealed opportunities for improvement in obtaining current, accurate patient weights.

"There is a direct correlation between having accurate patient weight and positive patient outcomes, said Regina Hoffman, the Authority's executive director.  "Patient weight, if inaccurate, outdated, misinterpreted, or missing, can increase the likeliness of patient harm."

The final recommendations, published in the September 8, 2018, Pennsylvania Bulletin, calls out the failures to weigh patients in kilograms and document patient weights in kilograms as a significant contributing factor to medication errors. Further, the recommendations note that this problem often starts at the onset of the patient encounter and continues to put patients at risk throughout their course of care and treatment.

"The estimation of weight from both clinicians and caregivers, and the absence of proper weight scales are some instances that contribute to weight based errors," says Hoffman.  These recommendations offer actionable steps that health care facilities should implement to protect patients now."

In accordance with the Medical Care Availability and Reduction of Error Act, the Authority is responsible for submitting recommendations to the Pennsylvania Department of Health (the Department) for changes in health care practices and procedures which may be instituted for the purpose of reducing the number and severity of serious events and incidents. Once approved by the Department, the Authority is responsible for issuing those recommendations.

The Pennsylvania Bulletin includes final recommendations and considerations to the following; expectation of improved quality care, implementation feasibility, other relevant implementation practices, and the cost impact to patient and medical facilities. 

Accompanying the final recommendations, the Authority has made available a patient safety topic that includes peer reviewed journal articles, a checklist tool, and a safety tip for patients.

For more information about the Authority, patient safety topics, Advisory articles, and safety tips for patients, please visit patientsafety.pa.gov.

The Authority's mission is to improve the quality of healthcare in Pennsylvania by collecting and analyzing patient safety information, developing solutions to patient safety issues, and sharing this information through education and collaboration. Its vision is safe healthcare for all patients.

©2018 Pennsylvania Patient Safety Authority