PITANJE
Why do medication errors keep happening?
Potrošite nalepnice na ono što je najvažnije. Ideja sa dokazom može da zauzme rezervisano mesto.
zatvoreno · nazad na fazu Akcije
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Vaš broj nalepnica
Jedna po ideji, ukupno 5. Najmanje jedan glas.
Rezervisana mesta za previđene ideje: 5 — nominujte jednu uz link, i ona se računa kada se dovoljno ljudi (2) složi da je izvor relevantan.
zašto
Kada se faza zatvori, jedan nominovani ulazi slučajnim izvlačenjem, a ostali po broju nominacija, najviše jedan po klasi zainteresovanih strana. Model proverava samo da li stranica govori o istoj temi — nikad da li dokazuje tvrdnju. Ta procena pripada sobi, a nominacija iza koje niko drugi ne stoji ne dobija mesto.
The same error recurs on the same drug every few months
Meaning the recurring pattern, not the one incident under review.
Još ništa nije rečeno.
KLASTER 1
Allergy information is in a different system from the prescribing one
glasova: 3diskutuj
Training on the prescribing system was a one-hour session two years ago
To be precise: this is about the system, not any nurse or doctor.
glasova: 2diskutuj
KLASTER 2
Infusion pumps on the ward come from three manufacturers
glasova: 5diskutuj
The same look-alike drugs are stored next to each other
glasova: 5diskutuj
KLASTER 3
Near misses are not reported because the form takes twenty minutes
glasova: 7diskutuj
Reporting an error has led to disciplinary action in the past
glasova: 3diskutuj
KLASTER 4
Handwritten charts are still used when the system is down, which is often
glasova: 9diskutuj
The electronic chart times out and loses the entry
glasova: 2diskutuj
KLASTER 5
Verbal orders are accepted over the phone without read-back
glasova: 0diskutuj
Double-checking is signed without a second person actually looking
Meaning the recurring pattern, not the one incident under review.
glasova: 9
↳ nominovano za rezervisano mesto: https://example.org/ops-incident-review.pdf could not read it (HTTPError) podrška: 1 od 2
diskutujVAN KLASTERA
Pharmacy reviews charts a day after the first dose was given
glasova: 3diskutuj
The ward manager spends most of the shift covering gaps in the rota
glasova: 2diskutuj
Errors are discussed as individual mistakes, not as patterns
To be precise: this is about the system, not any nurse or doctor.
glasova: 8diskutuj
The same error recurs on the same drug every few months
Meaning the recurring pattern, not the one incident under review.
glasova: 5u fokusu ↑ · zatvori ✕
Nurses are measured on completing the round on time
glasova: 2diskutuj
Staffing is set by bed count, not by how sick the patients are
glasova: 0diskutuj
Agency staff do not know the ward's conventions
glasova: 14diskutuj
Patients are moved between wards mid-treatment and the chart lags behind
glasova: 2diskutuj
New nurses are put on drug rounds in their first week
glasova: 2diskutuj
The drug trolley is shared between two bays
glasova: 0diskutuj
Discharge medication lists disagree with the inpatient chart
glasova: 13diskutuj
Nobody looks at the error reports together
glasova: 1diskutuj
Night shift has one nurse for the whole bay
glasova: 9diskutuj
Prescriptions are written in the corridor between other tasks
glasova: 1diskutuj
Interruptions during the drug round are constant
glasova: 9diskutuj
Alerts in the system are so frequent that they are clicked through
Scope: this ward on this site, not the trust as a whole.
glasova: 15diskutuj
Weight-based doses are calculated by hand at the bedside
glasova: 5diskutuj
Doctors change doses verbally on the round and the chart is updated later
Meaning the recurring pattern, not the one incident under review.
glasova: 0diskusija (1)