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BMJ Qual Improv Report 6: doi:10.1136/bmjquality.u214416.w5476
  • BMJ Quality Improvement Programme

Elimination of Emergency Department Medication Errors Due To Estimated Weights

  1. Jim Wilkerson
  1. Midwest Healthcare Quality Alliance
  1. Correspondence to Mary Greenwalt greenwalt.mary{at}mhsil.com
  • Received 17 August 2016
  • Revision requested 6 October 2016
  • Revised 19 December 2016
  • Published 27 March 2017

Abstract

From 7/2014 through 6/2015, 10 emergency department (ED) medication dosing errors were reported through the electronic incident reporting system of an urban academic medical center. Analysis of these medication errors identified inaccurate estimated weight on patients as the root cause. The goal of this project was to reduce weight-based dosing medication errors due to inaccurate estimated weights on patients presenting to the ED. Chart review revealed that 13.8% of estimated weights documented on admitted ED patients varied more than 10% from subsequent actual admission weights recorded. A random sample of 100 charts containing estimated weights revealed 2 previously unreported significant medication dosage errors (.02 significant error rate). Key improvements included removing barriers to weighing ED patients, storytelling to engage staff and change culture, and removal of the estimated weight documentation field from the ED electronic health record (EHR) forms. With these improvements estimated weights on ED patients, and the resulting medication errors, were eliminated.

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