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Why do medication errors keep happening?
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perché
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Handwritten charts are still used when the system is down, which is often
raggruppamento 4
Ancora nessun intervento.
RAGGRUPPAMENTO 1
Allergy information is in a different system from the prescribing one
voti: 3discuti
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.
voti: 2discuti
RAGGRUPPAMENTO 2
Infusion pumps on the ward come from three manufacturers
voti: 5discuti
The same look-alike drugs are stored next to each other
voti: 5discuti
RAGGRUPPAMENTO 3
Near misses are not reported because the form takes twenty minutes
voti: 7discuti
Reporting an error has led to disciplinary action in the past
voti: 3discuti
RAGGRUPPAMENTO 4
Handwritten charts are still used when the system is down, which is often
voti: 9in primo piano ↑ · chiudi ✕
The electronic chart times out and loses the entry
voti: 2discuti
RAGGRUPPAMENTO 5
Verbal orders are accepted over the phone without read-back
voti: 0discuti
Double-checking is signed without a second person actually looking
Meaning the recurring pattern, not the one incident under review.
voti: 9
↳ candidata a un posto riservato: https://example.org/ops-incident-review.pdf could not read it (HTTPError) a sostegno: 1 su 2
discutiNON RAGGRUPPATA
Pharmacy reviews charts a day after the first dose was given
voti: 3discuti
The ward manager spends most of the shift covering gaps in the rota
voti: 2discuti
Errors are discussed as individual mistakes, not as patterns
To be precise: this is about the system, not any nurse or doctor.
voti: 8discuti
The same error recurs on the same drug every few months
Meaning the recurring pattern, not the one incident under review.
voti: 5discuti
Nurses are measured on completing the round on time
voti: 2discuti
Staffing is set by bed count, not by how sick the patients are
voti: 0discuti
Agency staff do not know the ward's conventions
voti: 14discuti
Patients are moved between wards mid-treatment and the chart lags behind
voti: 2discuti
New nurses are put on drug rounds in their first week
voti: 2discuti
The drug trolley is shared between two bays
voti: 0discuti
Discharge medication lists disagree with the inpatient chart
voti: 13discuti
Nobody looks at the error reports together
voti: 1discuti
Night shift has one nurse for the whole bay
voti: 9discuti
Prescriptions are written in the corridor between other tasks
voti: 1discuti
Interruptions during the drug round are constant
voti: 9discuti
Alerts in the system are so frequent that they are clicked through
Scope: this ward on this site, not the trust as a whole.
voti: 15discuti
Weight-based doses are calculated by hand at the bedside
voti: 5discuti
Doctors change doses verbally on the round and the chart is updated later
Meaning the recurring pattern, not the one incident under review.
voti: 0discussione (1)