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

Hirata, Kristin M. BA; Kang, Ann H. MD; Ramirez, Gina V. MD; Kimata, Chieko PhD, MPH, MBA; Yamamoto, Loren G. MD, MPH, MBA

doi: 10.1097/PEC.0000000000001277
Original Articles

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.

From the Department of Pediatrics, University of Hawai'i John A. Burns School of Medicine, Kapi'olani Medical Center for Women & Children, Honolulu, HI.

This study was supported by Hawai'i Pacific Health's Summer Student Research Program.

Disclosure: The authors declare no conflict of interest.

Reprints: Loren G. Yamamoto, MD, MPH, MBA, Department of Pediatrics, University of Hawai'i John A. Burns School of Medicine, 1319 Punahou St, 7th Floor, Honolulu, HI 96826 (e-mail:

Online date: October 3, 2017

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