THE QUESTION
Why do medication errors keep happening?
Group cards you judge alike. Groups organise reading; they decide nothing.
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Clusters form from similarity, names come last
Canonical order: link pairs of ideas you judge similar — links are symmetric (A~B is B~A; direction never matters) and a tie holds once 2 members make it.
why
Links are symmetric — A~B is B~A. Clusters are the groups that emerge from held ties, and only a formed cluster can be named, by a person. Your own links carry a ✕ to withdraw; you cannot remove someone else's. Clusters organise the wall and never gate the vote — two cards making the same CLAIM are a merge back in Clarify.
Links and names are made while Cluster is live; the steward’s ← reopens it.
unnamed cluster — name it if the group has a common thread, or leave it unnamed (2)
Handwritten charts are still used when the system is down, which is often
~ The electronic chart …The electronic chart times out and loses the entry (20)
The electronic chart times out and loses the entry
~ Handwritten charts ar…Handwritten charts are still used when the system is down, which is often (20)
unnamed cluster — name it if the group has a common thread, or leave it unnamed (2)
Verbal orders are accepted over the phone without read-back
~ Double-checking is si…Double-checking is signed without a second person actually looking (16)
Double-checking is signed without a second person actually looking
~ Verbal orders are acc…Verbal orders are accepted over the phone without read-back (16)
unnamed cluster — name it if the group has a common thread, or leave it unnamed (2)
The same look-alike drugs are stored next to each other
~ Infusion pumps on the…Infusion pumps on the ward come from three manufacturers (9)
Infusion pumps on the ward come from three manufacturers
~ The same look-alike d…The same look-alike drugs are stored next to each other (9)
unnamed cluster — name it if the group has a common thread, or leave it unnamed (2)
Allergy information is in a different system from the prescribing one
~ Training on the presc…Training on the prescribing system was a one-hour session two years ago (17)
Training on the prescribing system was a one-hour session two years ago
~ Allergy information i…Allergy information is in a different system from the prescribing one (17)
unnamed cluster — name it if the group has a common thread, or leave it unnamed (2)
Near misses are not reported because the form takes twenty minutes
~ Reporting an error ha…Reporting an error has led to disciplinary action in the past (19)
Reporting an error has led to disciplinary action in the past
~ Near misses are not r…Near misses are not reported because the form takes twenty minutes (19)
· not yet clustered (18)
Pharmacy reviews charts a day after the first dose was given
The ward manager spends most of the shift covering gaps in the rota
Errors are discussed as individual mistakes, not as patterns
The same error recurs on the same drug every few months
Nurses are measured on completing the round on time
Staffing is set by bed count, not by how sick the patients are
Agency staff do not know the ward's conventions
Patients are moved between wards mid-treatment and the chart lags behind
New nurses are put on drug rounds in their first week
The drug trolley is shared between two bays
Discharge medication lists disagree with the inpatient chart
Nobody looks at the error reports together
Night shift has one nurse for the whole bay
Prescriptions are written in the corridor between other tasks
Interruptions during the drug round are constant
Alerts in the system are so frequent that they are clicked through
Weight-based doses are calculated by hand at the bedside
Doctors change doses verbally on the round and the chart is updated later