Weight and Height Juxtaposition in the Electronic Medical Record Causing an Accidental Medication Overdose.

https://psnet.ahrq.gov/web-mm/weight-and-height-juxtaposition-electronic-medical-record-causing-accidental-medication In this WebM&M Case a 2-year-old girl presented to the emergency department (ED) with joint swelling and rash following an upper respiratory infection. After receiving treatment and being discharged with a diagnosis of allergic urticaria, she returned the following day with worsening symptoms. Suspecting an allergic reaction to amoxicillin, the ED team prepared to administer methylprednisolone. However, the ED intake technician erroneously switched the patient’s height and weight in the electronic health record (EHR), resulting in an excessive dose being ordered and dispensed. An automatic error message was generated due to the substantial difference from previous weights, but this message was overlooked by the ED technician and the data entry error was not detected or corrected. The commentary discusses the importance of verifying medication orders before administration, optimizing alert notifications to minimize the risk of alert fatigue, and the role of root cause analysis to identify factors contributing to medication errors.