Following a significant harm event related to how patient weights were obtained at a hospital, the organization invested in replacing all hospital and clinic scales with metric-only scales; however, events continued to occur. Human factors were identified as the cause of pound/kilogram transcription errors, including poor conversion between pounds and kilograms and vital sign documentation practices, so two real-time alerts were added to the electronic health record which notify clinicians when patient heights or weights are entered that generate an extreme body mass index (BMI) value or when patient weights are entered that are significantly different than previously documented weights. This alert now allows staff to resolve weight discrepancies in almost real-time to prevent patient harm.
