{"id": "626fd23", "room": "3c4ac0e", "text": "Errors are discussed as individual mistakes, not as patterns", "url": "https://truecauses.org/c/3c4ac0e/626fd23-errors-discussed-individual-mistakes", "json": "https://truecauses.org/c/3c4ac0e/626fd23.json", "embed": "https://truecauses.org/embed/3c4ac0e/626fd23", "room_url": "https://truecauses.org/d/3c4ac0e", "question": "Why do medication errors keep happening?", "kind": "barriers", "relation": "significantly influences", "source": "walkthrough", "demonstration": true, "room_is": "a walkthrough with stand-ins — a demonstration, not a finding", "stands": false, "stage": 6, "sealed": true, "root": true, "shortlisted": true, "leads_to": ["0739b6a", "2bf4e59"], "comes_from": [], "links": [{"pair": "0739b6a>626fd23", "role": "effect", "other": {"id": "0739b6a", "text": "The same error recurs on the same drug every few months", "url": "https://truecauses.org/c/3c4ac0e/0739b6a-error-recurs-drug-months"}, "verdict": "no", "by": "panel", "votes": {"yes": 0, "no": 14, "abstain": 1}}, {"pair": "108bae0>626fd23", "role": "effect", "other": {"id": "108bae0", "text": "Allergy information is in a different system from the prescribing one", "url": "https://truecauses.org/c/3c4ac0e/108bae0-allergy-prescribing"}, "verdict": "no", "by": "panel", "votes": {"yes": 0, "no": 15, "abstain": 0}}, {"pair": "26628ad>626fd23", "role": "effect", "other": {"id": "26628ad", "text": "The same look-alike drugs are stored next to each other", "url": "https://truecauses.org/c/3c4ac0e/26628ad-look-alike-drugs-stored"}, "verdict": "no", "by": "cross-group", "votes": {"yes": 4, "no": 24, "abstain": 1}}, {"pair": "2bf4e59>626fd23", "role": "effect", "other": {"id": "2bf4e59", "text": "Near misses are not reported because the form takes twenty minutes", "url": "https://truecauses.org/c/3c4ac0e/2bf4e59-misses-reported-form-takes-minutes"}, "verdict": "no", "by": "panel", "votes": {"yes": 1, "no": 13, "abstain": 1}}, {"pair": "53baa1c>626fd23", "role": "effect", "other": {"id": "53baa1c", "text": "New nurses are put on drug rounds in their first week", "url": "https://truecauses.org/c/3c4ac0e/53baa1c-nurses-drug-rounds-week"}, "verdict": "no", "by": "panel", "votes": {"yes": 1, "no": 12, "abstain": 2}}, {"pair": "626fd23>0739b6a", "role": "cause", "other": {"id": "0739b6a", "text": "The same error recurs on the same drug every few months", "url": "https://truecauses.org/c/3c4ac0e/0739b6a-error-recurs-drug-months"}, "verdict": "yes", "by": "panel", "votes": {"yes": 12, "no": 3, "abstain": 0}}, {"pair": "626fd23>108bae0", "role": "cause", "other": {"id": "108bae0", "text": "Allergy information is in a different system from the prescribing one", "url": "https://truecauses.org/c/3c4ac0e/108bae0-allergy-prescribing"}, "verdict": "no", "by": "panel", "votes": {"yes": 0, "no": 13, "abstain": 2}}, {"pair": "626fd23>26628ad", "role": "cause", "other": {"id": "26628ad", "text": "The same look-alike drugs are stored next to each other", "url": "https://truecauses.org/c/3c4ac0e/26628ad-look-alike-drugs-stored"}, "verdict": "no", "by": "panel", "votes": {"yes": 1, "no": 11, "abstain": 3}}, {"pair": "626fd23>2bf4e59", "role": "cause", "other": {"id": "2bf4e59", "text": "Near misses are not reported because the form takes twenty minutes", "url": "https://truecauses.org/c/3c4ac0e/2bf4e59-misses-reported-form-takes-minutes"}, "verdict": "yes", "by": "panel", "votes": {"yes": 14, "no": 1, "abstain": 0}}, {"pair": "626fd23>53baa1c", "role": "cause", "other": {"id": "53baa1c", "text": "New nurses are put on drug rounds in their first week", "url": "https://truecauses.org/c/3c4ac0e/53baa1c-nurses-drug-rounds-week"}, "verdict": "no", "by": "cross-group", "votes": {"yes": 8, "no": 21, "abstain": 0}}, {"pair": "626fd23>7419dd4", "role": "cause", "other": {"id": "7419dd4", "text": "Patients are moved between wards mid-treatment and the chart lags behind", "url": "https://truecauses.org/c/3c4ac0e/7419dd4-patients-moved-wards-mid-treatment-chart"}, "verdict": "no", "by": "cross-group", "votes": {"yes": 7, "no": 22, "abstain": 0}}, {"pair": "626fd23>88f10f0", "role": "cause", "other": {"id": "88f10f0", "text": "Double-checking is signed without a second person actually looking", "url": "https://truecauses.org/c/3c4ac0e/88f10f0-double-checking-signed-person"}, "verdict": "no", "by": "panel", "votes": {"yes": 0, "no": 14, "abstain": 1}}, {"pair": "626fd23>cb1c7b1", "role": "cause", "other": {"id": "cb1c7b1", "text": "Discharge medication lists disagree with the inpatient chart", "url": "https://truecauses.org/c/3c4ac0e/cb1c7b1-discharge-medication-lists-disagree"}, "verdict": "no", "by": "panel", "votes": {"yes": 3, "no": 11, "abstain": 1}}, {"pair": "626fd23>e36cccd", "role": "cause", "other": {"id": "e36cccd", "text": "Alerts in the system are so frequent that they are clicked through", "url": "https://truecauses.org/c/3c4ac0e/e36cccd-alerts-frequent-clicked"}, "verdict": "no", "by": "panel", "votes": {"yes": 2, "no": 10, "abstain": 3}}, {"pair": "7419dd4>626fd23", "role": "effect", "other": {"id": "7419dd4", "text": "Patients are moved between wards mid-treatment and the chart lags behind", "url": "https://truecauses.org/c/3c4ac0e/7419dd4-patients-moved-wards-mid-treatment-chart"}, "verdict": "open", "by": "panel", "votes": {"yes": 0, "no": 10, "abstain": 5}}, {"pair": "88f10f0>626fd23", "role": "effect", "other": {"id": "88f10f0", "text": "Double-checking is signed without a second person actually looking", "url": "https://truecauses.org/c/3c4ac0e/88f10f0-double-checking-signed-person"}, "verdict": "no", "by": "panel", "votes": {"yes": 3, "no": 12, "abstain": 0}}, {"pair": "cb1c7b1>626fd23", "role": "effect", "other": {"id": "cb1c7b1", "text": "Discharge medication lists disagree with the inpatient chart", "url": "https://truecauses.org/c/3c4ac0e/cb1c7b1-discharge-medication-lists-disagree"}, "verdict": "no", "by": "panel", "votes": {"yes": 3, "no": 11, "abstain": 1}}, {"pair": "e36cccd>626fd23", "role": "effect", "other": {"id": "e36cccd", "text": "Alerts in the system are so frequent that they are clicked through", "url": "https://truecauses.org/c/3c4ac0e/e36cccd-alerts-frequent-clicked"}, "verdict": "no", "by": "cross-group", "votes": {"yes": 5, "no": 24, "abstain": 0}}], "atlas": {"id": "nf072704c795ddce8", "url": "https://truecauses.org/atlas?q=Errors%20are%20discussed%20as%20individual%20mistakes%2C%20not%20as%20patterns"}, "note": "a group’s judgement, not a measurement. Demo room", "attribution": "Causal map: True Causes, https://truecauses.org/d/3c4ac0e"}