Challenges With Measurement and Transcription of Patient Height: An Analysis of Patient Safety Events in Pennsylvania Related to Inaccurate Patient Height 

Authors

DOI:

https://doi.org/10.33940/data/2021.3.5

Keywords:

patient height, measurement, transcription, medication error, electronic medical record, patient safety, medication safety

Abstract

Visual abstract

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.

Author Biography

Elizabeth Kukielka, PharmD, MA, RPH, Patient Safety Authority

Elizabeth Kukielka (ekukielka@pa.gov) is a patient safety analyst on the Data Science and Research team at the Patient Safety Authority. Before joining the PSA, she was a promotional medical writer for numerous publications, including Pharmacy Times and The American Journal of Managed Care. Kukielka also worked for a decade as a community pharmacist and pharmacy manager, with expertise in immunization delivery, diabetes management, medication therapy management, and pharmacy compounding.

References

Byers D, France NE, Kuiper B. Measuring Height and Weight: From Research to Policy. Nursing. 2014;44(6):19-21. Epub 2014/05/21. doi: 10.1097/01.NURSE.0000444726.83265.c6. PubMed PMID: 24841601.

Tipton PH, Aigner MJ, Finto D, Haislet JA, Pehl L, Sanford P, et al. Consider the Accuracy of Height and Weight Measurements. Nursing. 2012;42(5):50-2. Epub 2012/04/26. doi: 10.1097/01.NURSE.0000413627.20475.a0. PubMed PMID: 22531077.

Medical Care Availability and Reduction of Error (MCARE) Act, Pub. L. No. 154 Stat. 13 (2002). Available from: https://www.health.pa.gov/topics/Documents/Laws%20and%20Regulations/Act%2013%20of%202002.pdf.

Beghetto MG, Fink J, Luft VC, de Mello ED. Estimates of Body Height in Adult Inpatients. Clin Nutr. 2006;25(3):438-43. Epub 2005/12/27. doi: 10.1016/j.clnu.2005.11.005. PubMed PMID: 16376463.

Bloomfield R, Steel E, MacLennan G, Noble DW. Accuracy of Weight and Height Estimation in an Intensive Care Unit: Implications for Clinical Practice and Research. Crit Care Med. 2006;34(8):2153-7. Epub 2006/06/10. doi: 10.1097/01.CCM.0000229145.04482.93. PubMed PMID: 16763505.

Leary TS, Milner QJ, Niblett DJ. The Accuracy of the Estimation of Body Weight and Height in the Intensive Care Unit. Eur J Anaesthesiol. 2000;17(11):698-703. Epub 2000/10/13. doi: 10.1046/j.1365-2346.2000.00751.x. PubMed PMID: 11029569.

Hendershot KM, Robinson L, Roland J, Vaziri K, Rizzo AG, Fakhry SM. Estimated Height, Weight, and Body Mass Index: Implications for Research and Patient Safety. J Am Coll Surg. 2006;203(6):887-93. Epub 2006/11/23. doi: 10.1016/j.jamcollsurg.2006.08.018. PubMed PMID: 17116557.

Santell JP, Kowiatek JG, Weber RJ, Hicks RW, Sirio CA. Medication Errors Resulting From Computer Entry by Nonprescribers. Am J Health Syst Pharm. 2009;66(9):843-53. Epub 2009/04/24. doi: 10.2146/ajhp080208. PubMed PMID: 19386948.

Goodloe R, Farber-Eger E, Boston J, Crawford DC, Bush WS. Reducing Clinical Noise for Body Mass Index Measures Due to Unit and Transcription Errors in the Electronic Health Record. AMIA Jt Summits Transl Sci Proc. 2017:102-11. PubMed Central PMCID: PMC5543370.

ISMP List of High-Alert Medications in Acute Care Settings: Institute for Safe Medication Practices; 2018 [updated August 23, 2018; accessed November 28, 2020]. Available from: https://www.ismp.org/recommendations/high-alert-medications-acute-list.

Freitag E, Edgecombe G, Baldwin I, Cottier B, Heland M. Determination of Body Weight and Height Measurement for Critically Ill patients Admitted to the Intensive Care Unit: A Quality Improvement Project. Aust Crit Care. 2010;23(4):197-207. Epub 2010/06/26. doi: 10.1016/j.aucc.2010.04.003. PubMed PMID: 20576445.

Venkataraman R, Ranganathan L, Nirmal V, Kameshwaran J, Sheela CV, Renuka MV, et al. Height Measurement in the Critically Ill Patient: A Tall Order in the Critical Care Unit. Indian J Crit Care Med. 2015;19(11):665-8. Epub 2016/01/06. doi: 10.4103/0972-5229.169342. PubMed PMID: 26730118; PubMed Central PMCID: PMCPMC4687176.

Frid H, Adolfsson ET, Rosenblad A, Nydahl M. Agreement Between Different Methods of Measuring Height in Elderly Patients. J Hum Nutr Diet. 2013;26(5):504-11. Epub 2013/01/09. doi: 10.1111/jhn.12031. PubMed PMID: 23294051.

patient chart with weight, height and medication dose, with waiting room in background

Published

2021-03-17

How to Cite

Kukielka, E. (2021). Challenges With Measurement and Transcription of Patient Height: An Analysis of Patient Safety Events in Pennsylvania Related to Inaccurate Patient Height . Patient Safety, 3(1), 48–57. https://doi.org/10.33940/data/2021.3.5

Issue

Section

Original Research and Articles
Bookmark and Share