There were similar reports a few years ago involving blood glucose meters that were switchable between two different measurement units. There was no prevarication on the part of the authorities in that occasion.

08 June 2006 – MHRA issues urgent safety warning about blood glucose meters
http://www.ukmicentral.nhs.uk/headline/database/story.asp?NewsID=5243

“There have been a number of reports of adverse incidents where the units of measurement displayed on affected blood glucose meters have changed from mmol/L to mg/dL. Results displayed in mg/dL are 18 times higher than those expressed in mmol/L. The agency is concerned that this change in unit of measurement could lead users to think that the blood glucose result is high and thus alter the treatment regime, leading to self-administration of an insulin overdose and going into hypoglycaemic coma.”

“The manufacturer will replace, free of charge, affected meters with new ones for which the unit of measurement cannot be changed.”

Buyers’ guide – Blood glucose systems – May 2008
http://www.pasa.nhs.uk/pasa/Doc.aspx?Path=%5BMN%5D%5BSP%5D/NHSprocurement/CEP/Biochemistry/CEP08008.pdf

“MHRA recommends that the units of measurements for blood glucose systems in the UK are hard fixed to display results as mmol/l. Results expressed as mg/dl are higher by a factor of 18 than results expressed as mmol/l (ie 6.5 mmol/l will be expressed as 117 mg/dl). This could lead the user to think that the glucose result is high and thus alter the treatment regime.”

The problem was easily understood, and the solution was simple. All glucose meters should only show standard measurement units. The same should apply to weighing scales, and any measuring device used to calculate drug or medication doses.

How much power does the UK Weighing Federation have when it comes to deciding what type of scales or units on scales can be used or sold in the UK? If the UK Weighing Federation does have the right amount of pull, it would be simple for them to get an agreement among all companies producing and marketing weighing scales for the UK market to produce and provide scales that work only in SI units and stop providing scales that can be switched to other units. This would literally end the lingering use of extinct units.

Even older scales that are periodically tested, repaired, recalibrated, etc., can at that time have their dual ability either removed or disabled. Making it impossible to service or replace non-SI scales would accelerate the demise of the lingering use of extinct units.

This could also extend beyond hospital use. If it becomes impossible to purchase a dual scale for use in the markets, repair a broken imperial or dual scale or to recalibrate an older imperial scale, then the extinct units will die out quicker.

I wonder how much contact the UKMA has with the UK Weighing Federation to help rid the UK of remnant scales using extinct units.

How could a court apply blame to people who make decisions that favour non-SI units even if they are the cause of injury and death if it is perceived that these non-SI units are the standard among the people? First you have to make laws that require the strict use of SI and for personnel to be tested for a working knowledge of SI before they can be allowed to work in that profession. Once you legally establish SI as the only allowable working system then and only then can you apply blame if errors occur if you can prove the error was cause by an individual violating the rules.

The only prejudice that could result in making metric only imperative would come from those who would view any law requiring or favouring metric usage as going against the choice of the general population to use non-SI units and punishing them for that choice.

Even the NASA report following the loss of the Mars climate orbiter did not lay the blame firmly at the door of the real issue.

One has to suspect that if the solution makes the exclusive use of metric imperative some kind of prejudice overshadows it.

Many of the prestigious hospitals, such as the Mayo Clinic in Rochester Minnesota have switched to full metric use to combat medical errors. But the hospitals that serve the common people are a mess. It is no wonder that so many injuries and deaths result. It seems that hospitals that cater to the rich and famous are more careful then those that cater to the common masses.

Those who oppose metrication will blame the metric system for the ease at which decimal errors or prefix confusion can occur. But the real reason these errors occur is due to lack of familiarity with SI prefixes and working with decimal notation. Hospital personnel are trained to work with metric units in their education but that doesn’t mean they will learn it well or become proficient. They need to learn the units in school at a younger age and have the opportunity to use them daily as part of other measurements. Using grams and degrees Celsius inside the hospital environment and pounds and ounces outside is a disaster waiting to happen.

Has there ever been a study to see if the same type of medical errors or level of medical errors occurs in hospitals in progressive countries that have always been metric?

Whenever a medical error occurs in the hospital lawyers are quick to sue. Unfortunately the suits seldom address the source of the errors and a demand to correct them. If they did, then every hospital in the US would be working 100 % in SI and the burden of conversion to extinct units would be on the patient who would insist on them. It may be that hospital lawsuits are too much of a cash cow for the law suits to demand medical reform or else the source of easy revenue for the law firms would dry up.

http://www.livescience.com/health/081001-hospitals-deadly.html

where they write:

The definitive study on the problem, which served as a wake-up call, was a 1999 report by the Institute of Medicine of the National Academies. Titled “To Err Is Human: Building A Safer Health System,” it estimated that somewhere between 44,000 to 98,000 Americans die in hospitals each year as the result of medical errors. Just the lower estimate would make medical errors the eighth leading cause of death at the time (more than motor vehicle accidents, breast cancer or AIDS).

And:

http://www.reuters.com/article/idUSN2436463220070525

where they write:

CHICAGO (Reuters) – Children with cancer often get the wrong dose of chemotherapy or are given the drug at the wrong time, and many require treatment because of the errors, U.S. researchers said on Friday.

The problem has a lot to do with lack of common standards for delivering these life-saving, but highly toxic, drugs, said Dr. Marlene Miller, director of quality and safety at Johns Hopkins Children’s Center in Baltimore.

Miller and colleagues evaluated data on medication errors collected in a national database from 1999 to 2004.

They looked at a total of 829,492 errors reported in 29,802 patients.

Of the errors, 310 involved kids on chemotherapy. Of those mistakes, 85 percent reached the patient, and nearly 16 percent of those were serious enough to require additional care.

Miller likens the problem to the issues most parents face when trying to figure out how much of the analgesic ibuprofen to give a child because the dose must be calculated based on weight and age.

“That is a reality for every single dose of medicine we give to children. There is no normal dose. There is no comfort level. There is no ability to say that is clearly, egregiously, too much for this age,” Miller said in a telephone interview.

And

http://www.foxnews.com/story/0,2933,331164,00.html

where they say:

It was later discovered that the lead pharmacist on duty at the hospital the night before made a fatal mistake prescribing to Alyssa 330 milligrams of zinc, a nutritional supplement to help the baby’s metabolism, ABC reported.

The dosage was 1,000 times the 330 micrograms of zinc that the baby was supposed to receive.

And

http://drugtopics.modernmedicine.com/drugtopics/article/articleDetail.jsp?id=365727

where they say:

Decimal errors can result in a 10-fold, 100-fold, or even 1,000-fold overdose or underdose

A recent lawsuit alleges that a hospital patient received a 10-fold overdose of an analgesic, which resulted in a dangerous drop in blood pressure. As a result of an attempt to treat that condition, the patient became paralyzed and died. But it was the decimal error that apparently killed him.

Decimal errors need not occur if you choose metric system prefixes so that hospital workers use whole numbers, see: http://www.metricationmatters.com/docs/WholeNumberRule.pdf

Cheers,

Pat Naughtin
Geelong, Australia

Does anyone know how this issue is handled in the Republic of Ireland? Are all scales in doctor’s offices and hospitals already metric-only? I also wonder how this is handled in Canada, another bastion of muddledom!