Challenges With Measurement and Transcription of Patient Height: An Analysis of Patient Safety Events in Pennsylvania Related to Inaccurate Patient Height
An accurate patient height is necessary to calculate certain measurements (e.g., body surface area [BSA]) and lab values (e.g., creatinine clearance [CrCl]), which may be needed to assess renal, cardiac, and lung function and to calculate accurate medication doses. We queried the Pennsylvania Patien...
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| Format: | Article |
| Language: | English |
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Patient Safety Authority
2021-03-01
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| Series: | Patient Safety |
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| Online Access: | https://patientsafetyj.com/index.php/patientsaf/article/view/403 |
| _version_ | 1797717662407589888 |
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| author | Elizabeth Kukielka |
| author_facet | Elizabeth Kukielka |
| author_sort | Elizabeth Kukielka |
| collection | DOAJ |
| description | An accurate patient height is necessary to calculate certain measurements (e.g., body surface area [BSA]) and lab values (e.g., creatinine clearance [CrCl]), which may be needed to assess renal, cardiac, and lung function and to calculate accurate medication doses. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 679 event reports related to an inaccurate patient height. All events were classified by the reporting facility as incidents, meaning that the patient did not sustain an unanticipated injury or require the delivery of additional healthcare services. The most common care area group where an event occurred was outpatient/clinic (35.8%; 243 of 679). Events were categorized as being related to an error in transcription (72.5%; 492 of 679) or measurement (7.4%; 50 of 679), and the remainder were categorized as etiology of error unclear (20.2%; 137 of 679). The most common transcription errors were the use of the wrong unit of measurement, the transposition of another measurement with height, and typographical errors. Inaccurate patient heights most often led to errors in calculation of medication doses or laboratory values. The most common medication class involved in a dosing error was cancer chemotherapy. In order to ensure accuracy of patient height measurements, patients should be measured at the beginning of every healthcare encounter, units of measurement should be consistent from measurement to transcription into the electronic medical record, and estimated patient height should never be relied upon or recorded. |
| first_indexed | 2024-03-12T08:40:32Z |
| format | Article |
| id | doaj.art-2c422bf717eb45cfa69598e5d3945a8d |
| institution | Directory Open Access Journal |
| issn | 2641-4716 |
| language | English |
| last_indexed | 2024-03-12T08:40:32Z |
| publishDate | 2021-03-01 |
| publisher | Patient Safety Authority |
| record_format | Article |
| series | Patient Safety |
| spelling | doaj.art-2c422bf717eb45cfa69598e5d3945a8d2023-09-02T16:52:02ZengPatient Safety AuthorityPatient Safety2641-47162021-03-013110.33940/data/2021.3.5Challenges With Measurement and Transcription of Patient Height: An Analysis of Patient Safety Events in Pennsylvania Related to Inaccurate Patient HeightElizabeth Kukielka0Patient Safety AuthorityAn accurate patient height is necessary to calculate certain measurements (e.g., body surface area [BSA]) and lab values (e.g., creatinine clearance [CrCl]), which may be needed to assess renal, cardiac, and lung function and to calculate accurate medication doses. We queried the Pennsylvania Patient Safety Reporting System (PA-PSRS) and identified 679 event reports related to an inaccurate patient height. All events were classified by the reporting facility as incidents, meaning that the patient did not sustain an unanticipated injury or require the delivery of additional healthcare services. The most common care area group where an event occurred was outpatient/clinic (35.8%; 243 of 679). Events were categorized as being related to an error in transcription (72.5%; 492 of 679) or measurement (7.4%; 50 of 679), and the remainder were categorized as etiology of error unclear (20.2%; 137 of 679). The most common transcription errors were the use of the wrong unit of measurement, the transposition of another measurement with height, and typographical errors. Inaccurate patient heights most often led to errors in calculation of medication doses or laboratory values. The most common medication class involved in a dosing error was cancer chemotherapy. In order to ensure accuracy of patient height measurements, patients should be measured at the beginning of every healthcare encounter, units of measurement should be consistent from measurement to transcription into the electronic medical record, and estimated patient height should never be relied upon or recorded.https://patientsafetyj.com/index.php/patientsaf/article/view/403patient heightmeasurementtranscriptionmedication errorelectronic medical recordpatient safety |
| spellingShingle | Elizabeth Kukielka Challenges With Measurement and Transcription of Patient Height: An Analysis of Patient Safety Events in Pennsylvania Related to Inaccurate Patient Height Patient Safety patient height measurement transcription medication error electronic medical record patient safety |
| title | Challenges With Measurement and Transcription of Patient Height: An Analysis of Patient Safety Events in Pennsylvania Related to Inaccurate Patient Height |
| title_full | Challenges With Measurement and Transcription of Patient Height: An Analysis of Patient Safety Events in Pennsylvania Related to Inaccurate Patient Height |
| title_fullStr | Challenges With Measurement and Transcription of Patient Height: An Analysis of Patient Safety Events in Pennsylvania Related to Inaccurate Patient Height |
| title_full_unstemmed | Challenges With Measurement and Transcription of Patient Height: An Analysis of Patient Safety Events in Pennsylvania Related to Inaccurate Patient Height |
| title_short | Challenges With Measurement and Transcription of Patient Height: An Analysis of Patient Safety Events in Pennsylvania Related to Inaccurate Patient Height |
| title_sort | challenges with measurement and transcription of patient height an analysis of patient safety events in pennsylvania related to inaccurate patient height |
| topic | patient height measurement transcription medication error electronic medical record patient safety |
| url | https://patientsafetyj.com/index.php/patientsaf/article/view/403 |
| work_keys_str_mv | AT elizabethkukielka challengeswithmeasurementandtranscriptionofpatientheightananalysisofpatientsafetyeventsinpennsylvaniarelatedtoinaccuratepatientheight |