PASSPORT · WHAT THIS ROOM DID
Why do medication errors keep happening?
Every line is from the record. Nothing is computed for this page, and nothing is smoothed: a short list of disagreements means a room that agreed, not a room whose disagreements were tidied away.
| structures | obstacles |
| opened | 08 Sep 2026 |
| who answered | 30 people in 2 group(s) · participant: 30 |
| wrote blind | not recorded |
| claims | 28 written, 20 structured |
| links certified | 12 |
| rooms on this question | 1 · does not count toward the shared map |
| decided at | 75% of the votes cast |
| sealed | yes, members forgotten |
What it rests on- Errors are discussed as individual mistakes, not as patterns
- Double-checking is signed without a second person actually looking
- Handwritten charts are still used when the system is down, which is often
- Pharmacy reviews charts a day after the first dose was given
- Allergy information is in a different system from the prescribing one
- Near misses are not reported because the form takes twenty minutes
What it could not settlePublished as contested, never recorded as a no.
- none: every pair the room reached was settled
What was predicted to followWritten after the map settled. Nobody voted on it.
- Staff nights by acuity score, not by bed count — expected: fewer errors once the drug round cannot be interrupted — due 24 Mar 2027
What the room would doEach action judged against each root cause, at three quarters of the votes cast.
- Staff nights by acuity score, not by bed count
split: Pharmacy reviews charts a day after the first dose was given - A near-miss report that takes two minutes and never names a person
split: Handwritten charts are still used when the system is down, which is often - Protected drug rounds: a tabard and a rule that only a patient emergency interrupts
reduces: Handwritten charts are still used when the system is down, which is often
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