{"id": "d3463a1", "room": "3c4ac0e", "text": "Night shift has one nurse for the whole bay", "url": "https://truecauses.org/c/3c4ac0e/d3463a1-night-shift-nurse-bay", "json": "https://truecauses.org/c/3c4ac0e/d3463a1.json", "embed": "https://truecauses.org/embed/3c4ac0e/d3463a1", "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": false, "shortlisted": true, "leads_to": ["9ecd4e2"], "comes_from": ["61aa254"], "links": [{"pair": "35cf04a>d3463a1", "role": "effect", "other": {"id": "35cf04a", "text": "Handwritten charts are still used when the system is down, which is often", "url": "https://truecauses.org/c/3c4ac0e/35cf04a-handwritten-charts"}, "verdict": "no", "by": "panel", "votes": {"yes": 2, "no": 12, "abstain": 0}}, {"pair": "61aa254>d3463a1", "role": "effect", "other": {"id": "61aa254", "text": "Pharmacy reviews charts a day after the first dose was given", "url": "https://truecauses.org/c/3c4ac0e/61aa254-pharmacy-reviews-charts-day-dose"}, "verdict": "yes", "by": "panel", "votes": {"yes": 12, "no": 2, "abstain": 0}}, {"pair": "7011347>d3463a1", "role": "effect", "other": {"id": "7011347", "text": "Weight-based doses are calculated by hand at the bedside", "url": "https://truecauses.org/c/3c4ac0e/7011347-weight-based-doses-calculated-hand"}, "verdict": "no", "by": "panel", "votes": {"yes": 1, "no": 13, "abstain": 0}}, {"pair": "9ce61a7>d3463a1", "role": "effect", "other": {"id": "9ce61a7", "text": "Verbal orders are accepted over the phone without read-back", "url": "https://truecauses.org/c/3c4ac0e/9ce61a7-verbal-accepted-phone-read-back"}, "verdict": "no", "by": "panel", "votes": {"yes": 2, "no": 11, "abstain": 1}}, {"pair": "9ecd4e2>d3463a1", "role": "effect", "other": {"id": 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"d3463a1>f1b512c", "role": "cause", "other": {"id": "f1b512c", "text": "Infusion pumps on the ward come from three manufacturers", "url": "https://truecauses.org/c/3c4ac0e/f1b512c-infusion-pumps-ward-manufacturers"}, "verdict": "no", "by": "panel", "votes": {"yes": 0, "no": 14, "abstain": 0}}, {"pair": "df45549>d3463a1", "role": "effect", "other": {"id": "df45549", "text": "Reporting an error has led to disciplinary action in the past", "url": "https://truecauses.org/c/3c4ac0e/df45549-reporting-error-led-disciplinary-action"}, "verdict": "no", "by": "panel", "votes": {"yes": 1, "no": 12, "abstain": 1}}, {"pair": "ecba340>d3463a1", "role": "effect", "other": {"id": "ecba340", "text": "Agency staff do not know the ward's conventions", "url": "https://truecauses.org/c/3c4ac0e/ecba340-agency-staff-ward-conventions"}, "verdict": "no", "by": "panel", "votes": {"yes": 1, "no": 12, "abstain": 1}}, {"pair": "f1b512c>d3463a1", "role": "effect", "other": {"id": "f1b512c", "text": "Infusion pumps on the ward come from three manufacturers", "url": "https://truecauses.org/c/3c4ac0e/f1b512c-infusion-pumps-ward-manufacturers"}, "verdict": "no", "by": "panel", "votes": {"yes": 2, "no": 11, "abstain": 1}}], "atlas": {"id": "n1fee30ab5a21050f", "url": "https://truecauses.org/atlas?q=Night%20shift%20has%20one%20nurse%20for%20the%20whole%20bay"}, "note": "a group’s judgement, not a measurement. Demo room", "attribution": "Causal map: True Causes, https://truecauses.org/d/3c4ac0e"}