Sonali Muzumdar (firstname.lastname@example.org) has been the clin-ical informatics pharmacist at Mercy Hospital & Medical Center in Chicago for more than 12 years, where she is a member of the Medication Safety Committee and has worked on improving the hospital’s weight documentation process.
Background: The Institute for Safe Medication Practices (ISMP) has recommended that health systems implement preventive measures to decrease weight-based dosing errors.
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Problem: Despite a process improvement project that was implemented to meet ISMP’s goals, weight documentation discrepancies continue to occur.
Methods: The weight documentation process was reviewed and safety gaps were identified. Pharmacists were notified when patients had greater than 15% weight documentation discrepancy. Notifications were tracked before, during, and after process improvements within the electronic health record (EHR).
Interventions: Streamlining of weight documentation fields within nursing assessments, locking of bed scales, setting an expiration date for the weight documentation field, including a minimum and maximum on height and weight fields, real-time alert for nursing staff upon documentation, and staff education were part of the process improvement plan.
Results: Average monthly weight documentation errors decreased from 115 to 60 per month over the process improvement period.
Conclusion: Human factor errors can result in weight documentation discrepancies despite implement-ing ISMP’s targeted safety goals around weight documentation. A real-time pharmacy notification of weight documentation discrepancies should be required for hospital pharmacists to prevent weight-based dosing errors.