Medication Safety: Inaccurate Patient Weight Can Cause Dosing Errors

May 27, 2014 | Healthcare Risk, Quality, & Safety Guidance


​Patient weighing, a long-standing practice in healthcare delivery, can contribute to serious and life-threatening medication errors if a patient's weight is obtained, recorded, or communicated incorrectly. A snapshot of medication errors reported to ECRI Institute PSO over a one-year period shows that weight-based dosing errors occur among patients of all ages (ECRI Institute PSO). Yet these events are entirely preventable if organizations adopt a multipronged approach to promote prompt and accurate patient weighing, correct documentation of the weight, and easy accessibility to the patient's information for those involved in medication management.

This article reviews weight-based medication dosing errors voluntarily reported to ECRI Institute PSO and recommends strategies to ensure patient weights are accurately obtained, documented, and communicated to the necessary staff involved in the patient's care. Refer to Strategies to Prevent Weight-Based Dosing Errors for a summary list of the recommendations.

ECRI Institute PSO, one of the first patient safety organizations (PSOs) to be federally certified under the Patient Safety and Quality Improvement Act of 2005 (PSQIA), recognizes the importance of sharing the findings and lessons learned from its analysis of aggregated event data. PSQIA established the groundwork for providers to voluntarily report patient safety events to PSOs in a protected environment. By collecting data from many providers, PSOs can spot problems and trends that an individual organization, with a limited pool of data, may be unable to detect. ECRI Institute PSO's findings about weight-based dosing errors were first reported in the February 2014 issue of its advisory, the PSO Navigator.

Medication dosing is often calculated on the basis of a patient's weight, particularly for pediatric patients, who require individualized dose calculations based on their size. Certain drugs given to adults—including some high-alert medications, such as anticoagulants and chemotherapeutic agents—must be administered at doses calculated on the basis of the patient's weight. Programming an intravenous medication dose and delivery rate for an...

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