Pediatric Weight Errors and Resultant Medication Dosing Errors in the Emergency Department

Pediatr Emerg Care. 2019 Sep;35(9):637-642. doi: 10.1097/PEC.0000000000001277.

Abstract

Background: An accurate weight is critical for dosing medications in children. Weight errors can lead to medication-dosing errors.

Objectives: This study examined the frequency and consequences of weight errors occurring at 1 children's hospital and 2 general hospitals.

Methods: Using an electronic medical record database, 79,000 emergency department encounters of children younger than 5 years were analyzed. Extreme weights were first identified using weight percentiles. Encounters with potential weight errors were further evaluated using a retrospective chart review to determine whether a weight error and medication-dosing error occurred.

Results: The percentage of weight errors of total encounters at all 3 institutions was low (0.63% on average), but a large proportion of weight errors led to subsequent medication-dosing errors (34% on average). The children's hospital did not have clinically significantly lower occurrences of weight errors or weight-based medication errors. Common weight errors included the weight in pounds being substituted for the weight in kilograms and decimal placement errors.

Conclusions: Weight errors were uncommon at the 3 emergency departments that we studied, but they led to weight-based medication-dosing errors that had the potential to cause harm.

Publication types

  • Multicenter Study

MeSH terms

  • Body Weight*
  • Child, Preschool
  • Emergency Service, Hospital / statistics & numerical data*
  • Growth Charts
  • Humans
  • Infant
  • Medication Errors / adverse effects
  • Medication Errors / statistics & numerical data*
  • Retrospective Studies