Six months after an official report warned of systemic negligence in medical weighing practice within the NHS, the Department of Health has failed to issue the necessary safety alert to hospital trusts to ensure that the report’s recommendations are implemented.
After a series of pilot studies in 2007 found some hospital staff using inaccurate or unsuitable scales to calculate dosages of medication for patients, including small children, LACORS (the Local Authorities Coordinators of Regulatory Services) set up the National Medical Weighing Project.
Interim Report – August 2008
Published in August 2008, the project’s interim report noted,
- “Staff do not consider scales to be medical equipment”
- “The amount of cheap bathroom scales in critical locations is astonishing”
- “One of the most potentially harmful issues is that of switchable scales – those that can display metric, imperial and other units. The risk is that medication could be administered based on a readout that was assumed to be metric.”
LACORS made a series of recommendations to hospital trusts, which included:
- All scales used for medical applications should be accuracy Class III or higher.
- Any equipment that is found to be inaccurate should be immediately removed from service and either repaired or replaced.
- All scales used for medical applications should only display metric units. There should be no capacity for switching or dual readouts. Trusts should be aware of the pitfalls of using switchable scales and may wish to consider replacing them.
The report pointed out that implementing its recommendations would lead to significant improvements in patient care, and the ability for hospital trusts to demonstrate due diligence in relevant clinical negligence claims.
Final Report – June 2009
Commenting on changes observed in hospitals that had been previously visited in 2008, the Final report of the LACORS National Medical Weighing Project 2008/9, published in June 2009, reiterated the earlier report’s findings:
“The area with the most room for improvement (and potential to cause harm) is scales capable of showing metric and imperial units. While numbers have decreased, nearly one third of all scales in use are switchable. A staggering one in ten of these was set to imperial at the time of testing, despite no medicines or treatments having doses calculated in imperial units.”
Department of Health
The Department of Health has a system for issuing safety bulletins and procedure updates to hospital trusts known as Estates Alerts.
In early 2008, a series of bungled contradictory estates alerts were issued by the DH concerning medical weighing; all of which failed to recommend that all new scales should be metric-only.
In December 2009, the UK Weighing Federation announced that it is working with LACORS to push the Department of Health to issue the much-needed safety alert.
Exclusively metric units are used for all medical purposes.
All drug doses are in metric, and are often calculated per patient body mass (mg/kg), or per surface area (mg/m²).
Tracking a patient’s weight is not straight-forward using imperial units. e.g. Calculating 10% of 75 kg is a trivial task, but finding 10% of 12 st 9 lb is more prone to errors because it is not so simple.
Babies have been weighed in kilograms for decades, although in recent years metric readings have been dumbed down to pounds and ounces for the ‘benefit’ of grandparents, sometimes without the mother being informed of the original metric weight.
Interim report of the National Medical Weighing Project
Final report of the LACORS National Medical Weighing Project 2008/9
Department of Health Estates Alerts
DH (2008) 05 – Patient weigh scales
DH 2008/05U Patient weigh scales – update
DH (2008) 05(2U) – Patient Weigh Scales 2nd Updated http://www.dh.gov.uk/en/Publicationsandstatistics/Lettersandcirculars/Estatesalerts/DH_085724