KEY POINTS:
Scales that weigh infants and children only in kilograms, rather than also in pounds and ounces, would reduce the risk of mistakes that could lead to medicine overdoses, says the Health and Disability Commission.
Deputy commissioner Rae Lamb investigated a case in which 1-month-old "Baby B" was given a maximum drug dose rather than the recommended dose at Palmerston North Hospital after having her weight recorded as 6.82kg. Her birth weight was 2.74kg and, when the error was discovered several days later and she was re-weighed, she weighed 3.7kg.
Initial tests showed no ill-effects from the overdose but high-range hearing damage is possible and cannot be excluded until she is old enough for testing.
Ms Lamb said babies and small children were particularly vulnerable to medication errors as almost all dosages were calculated on their weight.
"These sorts of errors can have serious and harmful consequences," she said. "Accuracy in measuring and recording an infant's weight before calculating any medication dosage is, therefore, crucial.
Ms Lamb said scales that measured only in kilograms would reduce the likelihood of wrongly recorded weights.
But they were not readily available - most recorded kilograms and pounds.
"Weighing and recording weights only in kilograms is an important step to prevent such errors, and I encourage all healthcare providers to avoid the use of pounds and ounces in the weighing of babies, infants and children," she said.
"Measures such as recording the child's weight on all documentation and visually confirming the child's weight at the bedside would provide additional opportunities for any error to be identified."
The hospital had put in place measures to prevent repeat incidents, including placing posters in the medication room alerting staff to check the accuracy of patient weights.
- NZPA
