This Signal relates to the risks associated with failing to ascertain and monitor accurate weight of children and adults.
A sample incident reads:
When checking the notes noticed 10mg oramorph had been given . No weight recorded or workings of how this had been worked out . On the childs estimated wt 20kg - 400 micrograms / kg = 8mg…. drug had been prescribed and 3 people signed for it without checking the dose as per paediatric doses with protocol.
Accurate patient weight is required for reasons such as establishing and monitoring nutritional status, accurate calculation and prescription of medicines (such as opiates and low molecular weight heparin) and fluid balance management. Frequently it is an essential piece of information when selecting appropriate equipment such as beds, chairs, trolleys and mattresses.
A search of the National Reporting and Learning System (NRLS) of incidents that occurred over four years revealed 27 reports of harm involving adults and children (one moderate, 23 severe and three deaths) where patients were not weighed, had inaccurate weights recorded (sometimes because estimates were used), or whose weight was not monitored over a period of time. This resulted in issues such as undetected or poorly managed malnutrition and incorrect doses of medicines.
It appears that availability of appropriate and accurate weighing equipment is a contributing factor, in addition to staff under-estimating the significance of accurate weight as an essential aspect of safe patient care. The importance of monitoring patient weight in preventing malnutrition is well known. In February 2006 NICE issued guidance on nutritional support in adults, while ‘Keeping nourished, getting better’ is one of the themes in the 2010 NHS Institute for Innovation and Improvement High Impact Interventions.
A DH Estates alert was issued in March 2010 following publication of a LACORS (Local Authorities Coordinators of Regulatory Services) final report in July 2009. Organisations are requested to develop action plans to address the report’s recommendations where they consider a risk to patient safety may exist.
Please contact us with information about your initiatives to reduce risks in any of these areas.
Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.