Weight-Based Medication Dose Errors

Failure to accurately measure and record a patient’s weight can contribute to serious, even fatal, dose errors, especially with high-alert medications such as anticoagulants and chemotherapeutic agents and in certain populations (e.g., children, elderly people).1 ISMP Canada recently received 3 reports of medication dosing incidents attributed to use of an incorrect patient weight. These incidents occurred in both hospital and community settings and resulted in or had the potential to cause patient harm. This bulletin highlights the sources of these errors, their implications, and a systems approach to reduce their occurrence.