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Measurement systems can lead to fatal medication errors

Although relatively rare given the number of patients who are treated every year in the country thousands of people, including those in Maryland and the Washington, D.C., area, fall victim to instances of medical malpractice in medical facilities every year. Among the most common errors are mistakes in pharmaceutical dosages. Such miscalculations often come when a patient's weight is converted from pounds to kilograms. Unfortunately, even a simple mathematical error can lead to a fatal drug overdose.

Some experts believe that widespread adoption of electronic health record-keeping systems has worsened the problem. Medical errors are far more likely when medical professionals who rely on these systems do not check the units being used. Default values are often set in one or the other measurement -- standard English based on the number 12 or international metric based on the number 10 -- and must be changed or have the input values converted before calculations are made. In fact, medical errors resulting from inaccurate metric-to-English and English-to-metric conversions are among the top concerns of patient safety professionals.

Other factors also can lead to miscalculations in drug dosages, including human input errors and the use of multiple measurement systems. Some experts also believe medical institutions have become overly reliant on technology.

To address this problem, many U.S. medical institutions have only been using metric systems, especially for weight measurements and pediatric dosing. Still, many health-care facilities have not made the switch and continue to use both traditional English measurements and metric measurements.

The problem is not easy to solve. For many institutions, tracking medical errors due to inaccurate conversions or conversion mistakes is not always done. For the protection of their patients and themselves, all administrators are strongly advised to switch all measurement systems to metric, even if the conversion is expensive in the short term.

Source: ModernHealthcare.com, "A gram of prevention: Providers urged to go metric to avoid medication errors," Sabriya Rice, May 1, 2015

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