Weighty Matters


Weighty matters

by Laura Mize

UF&Shands is working to eliminate one of the peskiest sources of medication errors in the U.S.: confusion between pounds and kilograms.

“Commonly reported throughout the country and in the medication safety literature are situations where a patient’s weight has inadvertently been reported in the wrong unit of measure,” said  Amy Rosenberg, Pharm.D., a pharmacy specialist in medication safety at Shands at UF. “This has resulted in either overdoses or underdoses.”

Many medications are dosed based on patient weight, and instructions for pharmacists always refer to that weight in kilograms, not pounds, Rosenberg said. With each kilogram equal to about 2.2 pounds, a dose based on pounds could be extremely inaccurate.

“This has been the biggest issue with medications that are high-alert medications, those medications for which, if there is a dosing error or a mistake, patients are at the highest risk for harm,” Rosenberg said.

Children also are at a greater risk, because most of their medications are administered based on weight.

Rosenberg said Shands is following recommendations the Institute for Safe Medication Practices gave last year after visiting at the hospital’s invitation, including “disabling any of our scales from being able to weigh in pounds.” Other recommendations included removing the term “pounds” from any forms or software used at Shands, which the hospital had mostly done before the  institute’s visit in February 2012.

The biggest adjustment, she said, comes in communicating with patients.

“Patients don’t like to hear their weight in kilograms, but we’re trying to take the time to explain the importance of why we’re only using kilograms for weighing them,” Rosenberg said. “If they’re unhappy with that, we can always convert that weight to pounds for them. We just don’t want to ever use that to actually weigh them, or use it in our medical record.”