True Causes
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ATLAS · A CLAIM AND WHERE IT CAME FROM

Errors are discussed as individual mistakes, not as patterns

Raised in 1 room

Why do medication errors keep happening?

→ What it leads to (2)

The same error recurs on the same drug every few months
certified in 1 room
Near misses are not reported because the form takes twenty minutes
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