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Safety Lesson Learned: Expressing pediatric weights in pounds is unsafe
Lessons Learned depict situations of risk from across the country. Events described did not necessarily happen at Children’s Hospitals and Clinics of Minnesota. Details have been changed and/or are a composite. The goal of studying these cases is to prevent similar occurrences.
Scenario: A child came in for day surgery and was weighed by the admitting nurse on a scale that shows both pounds and kilograms. The parents asked the nurse how much their child weighed in pounds, so the nurse told them the number, then entered that number in the space for kilograms on the admission form. This weight was then used to calculate the patient’s doses of anesthetic. Before any medications were given, the error was discovered by the anesthesiologist, who looked at the patient on the table and said, “You don’t look big enough to need this much medication!” Stopping the line enabled the team to review the entire medical history and locate the correct weight. Induction was resumed with dosages recalculated using the correct weight.
Discussion: While most of the world uses the metric system in all areas of life, the United States has two parallel systems: the “English” system (ounces, pounds, inches, yards, teaspoons, cups, fluid ounces, quarts, and gallons) used by the general population, and the metric system used in health care, science, avionics, the military, and a few other specialized areas.
One of the most dangerous intersections of these parallel systems is in pediatric health care, where dosages are prescribed by weight in kilograms and patient weights can vary as much as 500% (from 0.5 kg to 100 kg or more). The health care industry’s insistence on using metric measurements may be experienced by families as cold and alienating. Historical traditions and the popular press condition parents to think of their child’s size and growth in terms of pounds and inches, but the use of these units when accessing health care creates a high risk for error.
Anticipated improvement: All scales used to weigh patients in in-patient pediatric settings will express weights in metric units only. If the family requests the weight in pounds, a conversion chart may be used, but only after the weight in kilograms has been entered correctly in the patient’s medical record.
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