THE QUESTION
Why do medication errors keep happening?
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why
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Errors are discussed as individual mistakes, not as patterns
To be precise: this is about the system, not any nurse or doctor.
Nothing said yet.
CLUSTER 1
Allergy information is in a different system from the prescribing one
3 votesdiscuss
Training on the prescribing system was a one-hour session two years ago
To be precise: this is about the system, not any nurse or doctor.
2 votesdiscuss
CLUSTER 2
Infusion pumps on the ward come from three manufacturers
5 votesdiscuss
The same look-alike drugs are stored next to each other
5 votesdiscuss
CLUSTER 3
Near misses are not reported because the form takes twenty minutes
7 votesdiscuss
Reporting an error has led to disciplinary action in the past
3 votesdiscuss
CLUSTER 4
The electronic chart times out and loses the entry
2 votesdiscuss
Handwritten charts are still used when the system is down, which is often
9 votesdiscuss
CLUSTER 5
Verbal orders are accepted over the phone without read-back
0 votesdiscuss
Double-checking is signed without a second person actually looking
Meaning the recurring pattern, not the one incident under review.
9 votes
↳ nominated for a seat: https://example.org/ops-incident-review.pdf could not read it (HTTPError) 1 of 2 behind it
discussNOT CLUSTERED
Prescriptions are written in the corridor between other tasks
1 votesdiscuss
Patients are moved between wards mid-treatment and the chart lags behind
2 votesdiscuss
New nurses are put on drug rounds in their first week
2 votesdiscuss
Doctors change doses verbally on the round and the chart is updated later
Meaning the recurring pattern, not the one incident under review.
0 votesdiscussing (1)
Errors are discussed as individual mistakes, not as patterns
To be precise: this is about the system, not any nurse or doctor.
8 votesin focus ↑ · close ✕
The same error recurs on the same drug every few months
Meaning the recurring pattern, not the one incident under review.
5 votesdiscuss
Discharge medication lists disagree with the inpatient chart
13 votesdiscuss
Alerts in the system are so frequent that they are clicked through
Scope: this ward on this site, not the trust as a whole.
15 votesdiscuss
Nobody looks at the error reports together
1 votesdiscuss
The drug trolley is shared between two bays
0 votesdiscuss
Interruptions during the drug round are constant
9 votesdiscuss
Staffing is set by bed count, not by how sick the patients are
0 votesdiscuss
Weight-based doses are calculated by hand at the bedside
5 votesdiscuss
Nurses are measured on completing the round on time
2 votesdiscuss
The ward manager spends most of the shift covering gaps in the rota
2 votesdiscuss
Night shift has one nurse for the whole bay
9 votesdiscuss
Agency staff do not know the ward's conventions
14 votesdiscuss
Pharmacy reviews charts a day after the first dose was given
3 votesdiscuss