I am writing up a case study about a triage nurse who incorrectly recorded a toddler's weight as 25 kg, instead of 25 lbs (11.3kg). The weight error caused the toddler to receive 225 mg of clindamycin orally three times a day, instead of the correct dosage of 113 mg orally three times a day. Dosage was calculated for a toddler weighing 25kg instead of their actual weight of 11.3kg. Read the full case study at <http://webmm.ahrq.gov/case.aspx?caseID=293> http://webmm.ahrq.gov/case.aspx?caseID=293.
None of the other ER staff (who were different from the triage nurse) caught the error. To me this is an example of another issue most American's have with SI units- a lack of number sense! At least that is what I have been calling it. I am trying to clearly state that most Americans even in the healthcare field do not intuitively understand metric units. So even looking directly at the same toddler none of the other ER staff thought no way this kid is 25kg. A related thing happened to my son recently, during an allergy appointment at children's hospital here, he got on the scale and it said 10kg. My son is over 3 ft tall and weighs about 45lbs. My husband told the nurse, there is no way he weighs 10kg. The nurse replied, "that is what the scale said"- so he reminded her of the 2.2 conversion and she agreed. Turns out the digital scale was broken, but my point and how this story relates to the other story is that the nurse did not have a "number sense" of what 10kg would look like. She was looking directly at my son. Group- do you think the term "number sense" is correct in this context? Because it is not really the number but the unit attached to it which they do not intuitively understand. Any thoughts would be appreciated
