The Emergency Nurses Association (ENA) “Weighs in” on Pediatric Medication Safety: “Weigh Children in Kilograms Only!”

Abstract

Aresident enters a child’s weight of 44 into the information system as kilograms (Kg), when, in fact, the patient was weighed in pounds (lbs). The inaccuracy causes an overdose that results in the patient becoming fosphenytoin toxic. A pharmacist is consulted for Cubicin (DAPTOmycin) dosing on a patient. Checking the patient’s weight, the pharmacist notices that it has been entered into the computer as kilograms. The person who entered the weight failed to convert pounds to kilograms after weighing the patient on a scale that only measures in pounds. Had the error not been caught, the patient would have been given more than double the dosage. It has been clear for many years that the need to calculate medication based on weight for pediatric patients and the need to then calculate the dosages based on the various concentrations of medications is complicated enough. Adding yet another calculation―converting pounds to kilograms―and adding additional confusion regarding whether a child was even weighed in kilograms or pounds, is a recipe for disaster. After conducting a study on medication errors in the United States, the Institute of Medicine (IOM) estimated that, “on average, a hospital patient is subject to at least one medication error per day.” Some of the causes of the errors, such as look-alike medications and different concentrations of the same medication, are more difficult to correct, but others are easily corrected by acquiring a new scale for the department that weighs only in kilograms, or programming the computer to accept only kilograms. It is surprising, then, that a quick e-mail to nurse colleagues in emergency departments that see both adults and children revealed that, in 11 out of 12 responses, their emergency department had scales that weighed in both kilograms and pounds. One of the responses noted, “staff knows only to weigh in kilos.” Another said, “our computer automatically transposes the weight into kilograms, even if you put in pounds.” From yet another: “our scale does both, and we document in both during our triage assessment.” A number of responses mentioned the fact that parents liked to know the child’s weight in pounds. All of these responses reflect a number of chances for confusion and error. The IOM’s medication error study noted that children are “uniquely vulnerable to medication errors.” Because their medication dosages are based on body weight, the IOM believes that it is critically important to obtain accurate weights. Unfortunately, in a companion report, “Emergency Care for Children, Growing Pains,” the IOM cited that one of the pitfalls of pediatric emergency care is inaccurately obtained or recorded weights. This basic error leads to wrong dosages, which may often become 10-fold errors because of a missing or misread decimal point. Along with the IOM, numerous professional organizations and individuals have been calling for changes that will decrease medication errors in hospitalized children. For example, in 2001, the Pediatric Pharmacy Advocacy Group published guidelines and, in 2003, the American Academy of Pediatrics published several articles, both addressing Gail Lenehan is President of the Emergency Nurses Association and a CNS in the Emergency Department of the Massachusetts General Hospital, Boston, MA.