Spotlight Case

1. Spotlight Case A Weighty Mistake

2. Source and Credits • This presentation is based on the March 2013AHRQ WebM&M Spotlight Case • See the full article at http://webmm.ahrq.gov • CME credit is available • Commentary by: Seth J. Bokser, MD, MPH, Associate Professor of Pediatrics & Medical Director of Information Technology, UCSF Benioff Children’s Hospital • Editor, AHRQ WebM&M: Robert Wachter, MD • Spotlight Editor: Niraj Sehgal, MD, MPH • Managing Editor: Erin Hartman, MS

3. Objectives At the conclusion of this educational activity, participants should be able to: • Understand factors associated with weight-based medication dosing errors in pediatric populations • Describe how adoption of computerized provider order entry (CPOE) systems can introduce the risk of automation complacency • Identify strategies for reducing weight-based dosing medication errors

4. Case: A Weighty Mistake A 17-month-old toddler was brought to the emergency department (ED) by her parents, who had concerns about an infection around the eye. A triage nurse took the patient's vital signs, including her weight, and escorted her and the parents to a room for evaluation. The resident and attending physician diagnosed an uncomplicated periorbital cellulitis and prescribed clindamycin 225 mg orally three times daily based on the patient's weight. The patient received the first dose in the ED and was then discharged home.

5. Case: A Weighty Mistake (2) The following evening, the patient's mother called the ED to report that the patient's discharge paperwork listed a weight of 25 kg rather than her true weight of 25 lbs (11.3 kg). The mother, a medical student, realized the potential implications of such an error and asked the resident on duty to recalculate the appropriate dosage. The patient's dose was changed to 113 mg three times daily, and the patient continued the course with resolution of the cellulitis. Other than mild and self-limited diarrhea, there were no significant adverse effects from the four larger doses administered prior to the dose change. 5

6. Case: A Weighty Mistake (3) Upon further investigation, the initial triage nurse had incorrectly entered the patient's weight (25 pounds) as a weight in kilograms in the electronic medical record (EMR), an error that was not caught by other providers throughout the ED visit. 6

7. Background • Medication dosing for the pediatric patient is fraught with potential for error • Even with CPOE systems, incorrectly entered information can propagate seemingly obvious medication dosing errors • That is what occurred in this case See Notes for references.

8. Weight-Based Dosing • For patients under 40 kg, pediatric providers must calculate individualized medication doses based on the patient’s weight as a proxy for: • Physiologic development • Volume of drug distribution • This standard of pediatric practice is called “weight-based dosing”

9. Weight-Based Dosing Errors • USP’S MEDMARX database illustrated risk inherent in weight-based dosing by revealing: • One-third of pediatric medication errors were the result of “improper dose/quantity” (significantly higher than in adults) • 2.5% of those dosing errors led to patient harm See Notes for references.

10. CPOE as a Solution • Over past decade, emergence of CPOE systems has led to improvements in pediatric medication safety, particularly with associated clinical decision support tools • Pediatricians leverage the flawless math of computers to perform weight-based dosing calculations See Notes for references.

11. CPOE Automation Process • A multistep process: • Multiplying medication’s recommended weight-based daily dose (usually expressed in mg/kg) by the patient’s weight (expressed in kg) • Dividing that daily dose into desired interval for administration (in case described, three times daily) • Rounding that interval dose to match a measurable volume of pediatric suspension or breakable fraction of a tablet

12. Key Step in the Automation • Process is based on one foundational, patient-specific variable: weight expressed in kilograms • In era of EHRs and CPOE, once “bad data” is entered, patient safety is at risk for: • Medication dosing • Fluid resuscitation • Blood product delivery • Nutritional supplementation

13. Automation Complacency • Taking complex weight-based treatment calculations out of the hands of human clinicians leads to potential automation complacency • In our case, a clinician hand writing this patient’s weight (25 kg or 55 pounds)—rather than relying on automation—would have likely realized the computer-listed weight was incongruent with the 17-month-old child in front of her See Notes for reference.

14. Automation is a Safety Issue • A 2010 study demonstrated that of 479 medication errors related to obtaining and/or recording patient weight, 67% of the events reached the patient See Notes for reference.

15. Preventing Patient Harm • Given the importance of weight as a foundational piece of data in the integrated EHR, interventions must exist to support accurate measurement, recording, and display of pediatric weights

16. Recommendation #1 • A Guidelines for Care of Children in the Emergency Department joint policy statement recommends that every ED caring for pediatric patients must have a weight scale “that displays in kilograms only (not pounds) for infants and children” See Notes for reference.

17. Recommendation #2 • Because of confusion about kilograms versus pounds, clinicians should measure, record, and display weight in kilograms only in the EHR • Challenging because we live in a non-metric society and we often communicate with families in units they understand (e.g., Birth announcement: X pounds, Y ounces).

18. Recommendation #3 • Consider implementation of automated clinical decision support tools within EHR/CPOE systems • In this case, a rule-based algorithm might compare entered patient weight to expected weight in real-time to capture obvious discrepancies for the data-entry user

19. Recommendation #4 Biomedical device integration (the ability to integrate data from a digital medical device, such as scales, directly into the EHR) holds promise to limit human error inherent in observing and recording biometric data 19

20. Take-Home Points • In the era of integrated EMRs, where automated calculations and CDS algorithms drive patient care, bad foundational data (such as incorrectly entered patient weights) are dangerous. • CPOE systems have decreased dosing error rates associated with the complexity of weight-based dosing. Yet, they have also introduced the risk of automation complacency. Medication errors resulting from obtaining or recording incorrect patient weight have a high likelihood of reaching patients.

21. Take-Home Points (2) • To prevent data entry error of important values such as patient weight, systems and clinicians should follow these recommendations: • All providers who care for children should have access to infant and pediatric scales that weigh children in kilograms. • Standard of practice should be to measure, record, and display weight in kilograms in the clinician-facing EHR. • As pediatric providers continue to implement EHR software, they should consider building in decision support at the point of data entry for keys pieces of foundational information, such as weight. • EHR-integrated digital scale solutions can significantly limit the potential for patient weight–entry errors.