Accurate Weight Documentation: How To Adhere To Best Practices


  • Sonali Muzumdar



Background: The Institute for Safe Medication Practices (ISMP) has recommended that health systems implement preventive measures to decrease weight-based dosing errors.
Problem: Despite a process improvement project that was implemented to meet ISMP’s goals, weight documentation discrepancies continue to occur.
Methods: The weight documentation process was reviewed and safety gaps were identified. Pharmacists were notified when patients had greater than 15% weight documentation discrepancy. Notifications were tracked before, during, and after process improvements within the electronic health record (EHR).
Interventions: Streamlining of weight documentation fields within nursing assessments, locking of bed scales, setting an expiration date for the weight documentation field, including a minimum and maximum on height and weight fields, real-time alert for nursing staff upon documentation, and staff education were part of the process improvement plan.
Results: Average monthly weight documentation errors decreased from 115 to 60 per month over the process improvement period.
Conclusion: Human factor errors can result in weight documentation discrepancies despite implement-ing ISMP’s targeted safety goals around weight documentation. A real-time pharmacy notification of weight documentation discrepancies should be required for hospital pharmacists to prevent weight-based dosing errors.

Author Biography

Sonali Muzumdar

Sonali Muzumdar ( has been the clin-ical informatics pharmacist at Mercy Hospital & Medical Center in Chicago for more than 12 years, where she is a member of the Medication Safety Committee and has worked on improving the hospital’s weight documentation process.


Bailey BR, Gaunt MJ, Grissinger M. Update on Medication Errors Associated With Incorrect Pa-tient Weights. Pa Patient Saf Advis 2016;13(2):50-57.

Results of Pediatric Medication Safety Survey (Part 2): Comparing Data Subsets Points Out Areas For Improvement. July 2015. Available at: Accessed March 15, 2019.

Institute for Safe Medication Practices. 2018-2019 Targeted Medication Safety Best Practices for Hospitals. 2017. Available at: Accessed January 19, 2019.

Michalek C. ISMP’s Best Practices for Medi-cation Safety. Pharmacy Purchasing & Products 2018;15(9):8. Available at: https://www.pppmag. com/article/2285. Accessed January 19, 2019.

Bokser S. A Weighty Mistake. March 2013. Available at: Accessed January 19, 2019.

Institute for Safe Medication Practices Canada. Consumer Reports Submitted to Provide Insights Into Opportunities to Enhance Safety. ISMP Canada Saf Bulletin 2010;10(5):1-3.

The Joint Commission. Human Factors Analysis in Patient Safety Systems. The Source 2015;13(4):1-10. Available at: https://www. Accessed January 19, 2019.

Karsh BT, Holden RG, Alper SJ, et al. A Human Factors Engineering Paradigm for Patient Safety: Designing to Support the Performance of the Healthcare Professional.

Qual Saf Health Care 2006;15(Suppl I):i59-i65.

Woman standing on scale measuring in kg.



How to Cite

Muzumdar, S. . (2020). Accurate Weight Documentation: How To Adhere To Best Practices. Patient Safety, 2(1), 15–21.



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