THE QUESTION
Why do medication errors keep happening?
Propose what to do, then judge whether each action would move each root.
30 at the table (29 simulated) · 3 actions proposed against 5 root causes. Add one, then judge whether each action moves each cause.
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Score the roots first
why
The method's own practice, before any action is proposed: each root cause is scored 1–5 on how feasible it is to address, how much impact addressing it would have, and how likely it is to resolve by itself with no intervention. Priority goes to roots with high impact, high feasibility and low likelihood of fixing themselves — priority = impact + feasibility − likelihood. Scores are averaged across the group and shown with how many scored.
1 = low, 5 = high. Your own scores; the group's averages beside them.
| root cause | feasible | impact | fixes itself | priority |
|---|---|---|---|---|
| Pharmacy reviews charts a day after the first dose was given | – | |||
| Handwritten charts are still used when the system is down, which is often | – | |||
| Allergy information is in a different system from the prescribing one | – | |||
| Errors are discussed as individual mistakes, not as patterns | – | |||
| Double-checking is signed without a second person actually looking | – |
Would each action move each root cause?
Down the side: the actions people proposed. Across the top: the root causes the map found. Every square is one vote on one question — would this action significantly reduce that cause? One side has to reach 75% of the votes cast to settle it; short of that the square stays split.
why
Answered at 75% of votes cast, like every other question here. Split means people voted and neither side reached that bar — it is a result, not a queue, and it stays split until enough people change their minds. A square nobody settles stays undecided; it never turns into a no. Judging each pair on its own is what stops a popular action being credited with fixing things it does not touch.
| ACTION | ROOT CAUSES · does the action on the left reduce it? | ||||
|---|---|---|---|---|---|
| Pharmacy reviews charts a day after the first dose was given | Handwritten charts are still used when the system is down, which is often | Allergy information is in a different system from the prescribing one | Errors are discussed as individual mistakes, not as patterns | Double-checking is signed without a second person actually looking | |
| Protected drug rounds: a tabard and a rule that only a patient emergency interrupts discuss | ✗ no, it does not 5 yes / 24 no · 22 of 29 settles it | ✓ yes, it reduces this 27 yes / 2 no · 22 of 29 settles it | ✗ no, it does not 7 yes / 22 no · 22 of 29 settles it | ✗ no, it does not 7 yes / 22 no · 22 of 29 settles it | ✗ no, it does not 6 yes / 23 no · 22 of 29 settles it |
| Staff nights by acuity score, not by bed count in focus ↑ · close ✕ | ⚑ the group split 8 yes / 21 no · 22 of 29 settles it | ✗ no, it does not 2 yes / 27 no · 22 of 29 settles it | ✗ no, it does not 3 yes / 26 no · 22 of 29 settles it | ✗ no, it does not 4 yes / 25 no · 22 of 29 settles it | ✗ no, it does not 3 yes / 26 no · 22 of 29 settles it |
| A near-miss report that takes two minutes and never names a person discuss | ✗ no, it does not 3 yes / 26 no · 22 of 29 settles it | ⚑ the group split 8 yes / 21 no · 22 of 29 settles it | ✗ no, it does not 4 yes / 25 no · 22 of 29 settles it | ✗ no, it does not 2 yes / 27 no · 22 of 29 settles it | ✗ no, it does not 3 yes / 26 no · 22 of 29 settles it |
Highest leverage so far
Protected drug rounds: a tabard and a rule that only a patient emergency interrupts reduces 1 of 5 root causes