Christina Balsano Wichmann, MA, associate project director, Department of Standards and Survey Methods, and Helen Larios, MBA, MSN, RN, clinical project director, Department of Standards and Survey Methods
If 3.7% of your organization’s medication orders had errors pertaining to missing or inaccurate patient weights, would that be acceptable? That was the percent of weight-based errors for pediatric patients at two hospitals that participated in a six-week study.
This percentage could be even higher for pediatric and adult patients at other organizations. It's not uncommon for a health care organization to use both types of units of measurement: the traditional English system, and the metric system. Juggling two systems for patient weight and medication administration presents the potential for error because product labeling on medications for weight-based dosing uses only the metric system (e.g., mg/kg, units/kg).
Mistakes and inaccuracies in weight measurement can lead to medication dosing errors, which are particularly harmful to pediatric patients due to their small size. Joint Commission sentinel event data has also shown that severe harm or even death resulted when adult patients received the wrong dose of a medication due to an error in weight.
Data collected by the Institute for Safe Medication Practices (ISMP) Canada has shown that weighing patients incorrectly can occur for various reasons, including:
- incorrect unit of measure entry
- failure to enter unit of measure
- inaccurate estimation of patient weight
- use of a historical weight
- failure to correctly convert between pounds and kilograms
Environmental Assessment Survey
In 2017, The Joint Commission conducted an environmental assessment survey exploring attitudes and practices toward requiring pediatric patients to be weighed only in kilograms, as supported by available literature on the topic and recommended by several organizations.
Of the total survey respondents:
- 69% indicated that they were currently weighing pediatric patients in kilograms only
- 51% indicated that they were weighing adult patients in kilograms only
- other respondents indicated that they were using both pounds and kilograms to weigh patients or were using pounds only
- 98% of respondents have an electronic medical record system at their organization, but only 67% indicated that the system automatically converts pounds to kilograms
Commitment to Zero Harm
Although The Joint Commission is not planning to develop standards related to weighing patients in kilograms, it is committed to helping health care organizations transform the way they work to prevent harm. The Joint Commission’s commitment to patient safety goes beyond accreditation and certification. Through our Leading the Way to Zero initiative, we are collaborating with health care providers and organizations to identify and correct problems before they cause harm. Zero harm needs to be the natural result of how patient care is delivered every day.
Last fall, we invited professional organizations and key stakeholders to participate in a “Weighing All Patients in Kilograms” summit to discuss best practices, as well as barriers to implementation, for furthering progress toward safer medication administration practices. During the one-day summit, representatives from four hospitals/hospital systems that have successfully transitioned to weighing all patients in kilograms (AMITA Health Resurrection Medical Center, Knox Community Hospital, Mayo Clinic and the University of Iowa Stead Family Children’s Hospital) shared their best practices, implementation strategies and initial barriers to change.
Strategies shared by the presenters at the summit included the following:
- leadership and medical staff buy-in is integral
- collect and track weight-based errors via an incident reporting system
- an organizational guideline specific to weighing patients in kilograms (or grams for the nursery) needs to be developed and communicated
- educate all clinical staff, patients and families
- biomedical engineering department must inventory and change all scales’ default settings to kilograms (including beds and carts with scales); disable pounds/ounces
- replace scales that do not weigh in kilograms
- maintain scales and make sure they are calibrated correctly
- post laminate conversion charts for sharing weight in pounds to patients
- change paper forms from pounds to kilograms
- different electronic health record (EHR) systems throughout the organization make standardization difficult; one integrated system helps put the patient first
Participants of The Joint Commission’s summit and others have position statements and best practices regarding weighing patients in kilograms for health care leaders to consider, including:
- 2020-2021 ISMP Targeted Medication Safety Best Practices for Hospitals
- American Academy of Pediatrics position statement: “Weighing All Patients in Kilograms”
- Emergency Nurses Association position statement: “Weighing All Patients in Kilograms”
- National Coordinating Council for Medication Error Reporting and Prevention Recommendations to Weigh Patients and Document Metric Weights to Ensure Accurate Medication Dosing (adopted October 25, 2018)
One of ECRI’s “Top Ten Patient Safety Concerns for 2020” is standardizing safety across the system. In describing this concern, ECRI noted that “the modern health care system stretches beyond hospital walls, across continuums of care, and across state lines. A system’s culture of safety must have the same reach.” ECRI adds that “Achieving this goal requires standardizing practices, processes, procedures, and education. With this approach in place, a culture of safety across the system can be established.” Presenters at our summit acknowledged that making these changes across a system is not without its challenges, but it is possible to bring near misses and safety events to zero.
The Joint Commission believes that standardizing the practice of weighing patients in kilograms and then recording this weight across the continuum of care would decrease medication errors, especially for pediatric patients. Our goal is to encourage health care organizations to weigh all patients in kilograms and ultimately establish a new national norm for zero harm from weight-based medication dosing.
Christina Balsano Wichmann, MA, is associate project director in the Department of Standards and Survey Methods, Division of Healthcare Quality Evaluation, at The Joint Commission. Wichmann has been an editor and writer with The Joint Commission for 14 years. Prior to joining The Joint Commission, Wichmann was a grant writer for various social service agencies and a high school and college social sciences teacher.
Helen Larios, MBA, MSN, RN, is clinical project director in the Department of Standards and Survey Methods, Division of Healthcare Quality Evaluation, at The Joint Commission. Larios received Lean and Six Sigma and high reliability organizational training while employed at Advocate Good Samaritan Hospital, Downers Grove, Illinois. Prior to joining The Joint Commission, Larios held various managerial roles throughout surgical services with a specialized focus in orthopedics and spine in both acute inpatient and outpatient settings. Larios also served as a clinical mentor for Elmhurst College’s Nursing Master’s level program in Elmhurst, Illinois. Larios has over 15 years of clinical nursing experience that includes quality improvement, outcomes and project management.