True Causes
EN

ATLAS · A CLAIM AND WHERE IT CAME FROM

Near misses are not reported because the form takes twenty minutes

Raised in 1 room

Why do medication errors keep happening?

→ What leads to it (1)

Errors are discussed as individual mistakes, not as patterns
certified in 1 room

→ What it leads to (1)

The same look-alike drugs are stored next to each other
certified in 1 room

Every room keeps its own record: its map, its rules, and every judged pair with its votes, downloadable from the room. ← The atlas