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

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.