Estruturação · Why do medication errors keep happening?

A PERGUNTA

Why do medication errors keep happening?

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porquê

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decididos: 176 / 180 para responder: 0

Última contagem: decididos 176 · enviados a painéis entre grupos 1 · disputados 0 · abaixo do quórum 3 — os painéis precisam de pelo menos max(2, 75% do painel) votos expressos; o seu painel mais pequeno tem 15 membros.

fechar ✕

New nurses are put on drug rounds in their first week → influencia? → Errors are discussed as individual mistakes, not as patterns

Ainda nada foi dito.

Fase concluída — o registo de pares e votos mantém-se acima.Verificar a lógica ↗

Patients are moved between wards mid-treatment and the chart lags behind	→	Errors are discussed as individual mistakes, not as patterns	em aberto	discutir
…	→	Agency staff do not know the ward's conventions	em aberto	discutir
Pharmacy reviews charts a day after the first dose was given	→	Infusion pumps on the ward come from three manufacturers	em aberto	discutir
Agency staff do not know the ward's conventions	→	Interruptions during the drug round are constant	em aberto reencaminhado	discutir
Allergy information is in a different system from the prescribing one	→	The same look-alike drugs are stored next to each other	✓ sim	discutir
Allergy information is in a different system from the prescribing one	→	Alerts in the system are so frequent that they are clicked through	✓ sim	discutir
Patients are moved between wards mid-treatment and the chart lags behind	→	Discharge medication lists disagree with the inpatient chart	✓ sim	discutir
Near misses are not reported because the form takes twenty minutes	→	The same look-alike drugs are stored next to each other	✓ sim	discutir
Double-checking is signed without a second person actually looking	→	Patients are moved between wards mid-treatment and the chart lags behind	✓ sim	discutir
Errors are discussed as individual mistakes, not as patterns	→	The same error recurs on the same drug every few months	✓ sim	discutir
Errors are discussed as individual mistakes, not as patterns	→	Near misses are not reported because the form takes twenty minutes	✓ sim	discutir
Night shift has one nurse for the whole bay	→	Interruptions during the drug round are constant	✓ sim	discutir
Pharmacy reviews charts a day after the first dose was given	→	Night shift has one nurse for the whole bay	✓ sim	discutir
Infusion pumps on the ward come from three manufacturers	→	Agency staff do not know the ward's conventions	✓ sim	discutir
Handwritten charts are still used when the system is down, which is often	→	Infusion pumps on the ward come from three manufacturers	✓ sim	discutir
Double-checking is signed without a second person actually looking	→	Discharge medication lists disagree with the inpatient chart	✓ inferido	discutir
Double-checking is signed without a second person actually looking	→	Allergy information is in a different system from the prescribing one	✗ não	discutir
New nurses are put on drug rounds in their first week	→	The same error recurs on the same drug every few months	✗ não	discutir
The same look-alike drugs are stored next to each other	→	Double-checking is signed without a second person actually looking	✗ não	discutir
Discharge medication lists disagree with the inpatient chart	→	Allergy information is in a different system from the prescribing one	✗ não	discutir
The same look-alike drugs are stored next to each other	→	The same error recurs on the same drug every few months	✗ não	discutir
Alerts in the system are so frequent that they are clicked through	→	New nurses are put on drug rounds in their first week	✗ não	discutir
Discharge medication lists disagree with the inpatient chart	→	Near misses are not reported because the form takes twenty minutes	✗ não	discutir
Double-checking is signed without a second person actually looking	→	Alerts in the system are so frequent that they are clicked through	✗ não	discutir
Errors are discussed as individual mistakes, not as patterns	→	Patients are moved between wards mid-treatment and the chart lags behind	✗ não	discutir
Alerts in the system are so frequent that they are clicked through	→	The same error recurs on the same drug every few months	✗ não	discutir
The same error recurs on the same drug every few months	→	Patients are moved between wards mid-treatment and the chart lags behind	✗ não	discutir
Allergy information is in a different system from the prescribing one	→	Discharge medication lists disagree with the inpatient chart	✗ não	discutir
Discharge medication lists disagree with the inpatient chart	→	Patients are moved between wards mid-treatment and the chart lags behind	✗ não	discutir
The same error recurs on the same drug every few months	→	New nurses are put on drug rounds in their first week	✗ não	discutir
Errors are discussed as individual mistakes, not as patterns	→	Discharge medication lists disagree with the inpatient chart	✗ não	discutir
Discharge medication lists disagree with the inpatient chart	→	The same look-alike drugs are stored next to each other	✗ não	discutir
The same error recurs on the same drug every few months	→	Double-checking is signed without a second person actually looking	✗ não	discutir
The same error recurs on the same drug every few months	→	Alerts in the system are so frequent that they are clicked through	✗ não	discutir
The same error recurs on the same drug every few months	→	Allergy information is in a different system from the prescribing one	✗ não	discutir
The same look-alike drugs are stored next to each other	→	New nurses are put on drug rounds in their first week	✗ não	discutir
Near misses are not reported because the form takes twenty minutes	→	The same error recurs on the same drug every few months	✗ não	discutir
Near misses are not reported because the form takes twenty minutes	→	Errors are discussed as individual mistakes, not as patterns	✗ não	discutir
The same look-alike drugs are stored next to each other	→	Discharge medication lists disagree with the inpatient chart	✗ não	discutir
Errors are discussed as individual mistakes, not as patterns	→	Double-checking is signed without a second person actually looking	✗ não	discutir
Alerts in the system are so frequent that they are clicked through	→	Double-checking is signed without a second person actually looking	✗ não	discutir
Discharge medication lists disagree with the inpatient chart	→	Alerts in the system are so frequent that they are clicked through	✗ não	discutir
The same error recurs on the same drug every few months	→	Near misses are not reported because the form takes twenty minutes	✗ não	discutir
Double-checking is signed without a second person actually looking	→	The same error recurs on the same drug every few months	✗ não	discutir
New nurses are put on drug rounds in their first week	→	Patients are moved between wards mid-treatment and the chart lags behind	✗ não	discutir
Errors are discussed as individual mistakes, not as patterns	→	Alerts in the system are so frequent that they are clicked through	✗ não	discutir
The same look-alike drugs are stored next to each other	→	Patients are moved between wards mid-treatment and the chart lags behind	✗ não	discutir
The same look-alike drugs are stored next to each other	→	Alerts in the system are so frequent that they are clicked through	✗ não	discutir
New nurses are put on drug rounds in their first week	→	Discharge medication lists disagree with the inpatient chart	✗ não	discutir
Near misses are not reported because the form takes twenty minutes	→	Allergy information is in a different system from the prescribing one	✗ não	discutir
New nurses are put on drug rounds in their first week	→	Near misses are not reported because the form takes twenty minutes	✗ não	discutir
Double-checking is signed without a second person actually looking	→	Near misses are not reported because the form takes twenty minutes	✗ não	discutir
The same look-alike drugs are stored next to each other	→	Errors are discussed as individual mistakes, not as patterns	✗ não	discutir
Near misses are not reported because the form takes twenty minutes	→	Alerts in the system are so frequent that they are clicked through	✗ não	discutir
Errors are discussed as individual mistakes, not as patterns	→	Allergy information is in a different system from the prescribing one	✗ não	discutir
Patients are moved between wards mid-treatment and the chart lags behind	→	The same error recurs on the same drug every few months	✗ não	discutir
New nurses are put on drug rounds in their first week	→	Alerts in the system are so frequent that they are clicked through	✗ não	discutir
Double-checking is signed without a second person actually looking	→	The same look-alike drugs are stored next to each other	✗ não	discutir
The same error recurs on the same drug every few months	→	Discharge medication lists disagree with the inpatient chart	✗ não	discutir
The same look-alike drugs are stored next to each other	→	Allergy information is in a different system from the prescribing one	✗ não	discutir
Double-checking is signed without a second person actually looking	→	Errors are discussed as individual mistakes, not as patterns	✗ não	discutir
Near misses are not reported because the form takes twenty minutes	→	Discharge medication lists disagree with the inpatient chart	✗ não	discutir
Patients are moved between wards mid-treatment and the chart lags behind	→	The same look-alike drugs are stored next to each other	✗ não	discutir
Allergy information is in a different system from the prescribing one	→	Near misses are not reported because the form takes twenty minutes	✗ não	discutir
Discharge medication lists disagree with the inpatient chart	→	Errors are discussed as individual mistakes, not as patterns	✗ não	discutir
Allergy information is in a different system from the prescribing one	→	Errors are discussed as individual mistakes, not as patterns	✗ não	discutir
Discharge medication lists disagree with the inpatient chart	→	The same error recurs on the same drug every few months	✗ não	discutir
Patients are moved between wards mid-treatment and the chart lags behind	→	Allergy information is in a different system from the prescribing one	✗ não	discutir
Allergy information is in a different system from the prescribing one	→	Patients are moved between wards mid-treatment and the chart lags behind	✗ não	discutir
New nurses are put on drug rounds in their first week	→	Double-checking is signed without a second person actually looking	✗ não	discutir
Patients are moved between wards mid-treatment and the chart lags behind	→	New nurses are put on drug rounds in their first week	✗ não	discutir
Alerts in the system are so frequent that they are clicked through	→	Allergy information is in a different system from the prescribing one	✗ não	discutir
Errors are discussed as individual mistakes, not as patterns	→	New nurses are put on drug rounds in their first week	✗ não	discutir
Near misses are not reported because the form takes twenty minutes	→	New nurses are put on drug rounds in their first week	✗ não	discutir
New nurses are put on drug rounds in their first week	→	The same look-alike drugs are stored next to each other	✗ não	discutir
Alerts in the system are so frequent that they are clicked through	→	The same look-alike drugs are stored next to each other	✗ não	discutir
Patients are moved between wards mid-treatment and the chart lags behind	→	Alerts in the system are so frequent that they are clicked through	✗ não	discutir
Allergy information is in a different system from the prescribing one	→	The same error recurs on the same drug every few months	✗ não	discutir
Double-checking is signed without a second person actually looking	→	New nurses are put on drug rounds in their first week	✗ não	discutir
New nurses are put on drug rounds in their first week	→	Errors are discussed as individual mistakes, not as patterns	✗ não	em foco ↑ · fechar ✕
Near misses are not reported because the form takes twenty minutes	→	Double-checking is signed without a second person actually looking	✗ não	discutir
Alerts in the system are so frequent that they are clicked through	→	Patients are moved between wards mid-treatment and the chart lags behind	✗ não	discutir
Alerts in the system are so frequent that they are clicked through	→	Errors are discussed as individual mistakes, not as patterns	✗ não	discutir
Discharge medication lists disagree with the inpatient chart	→	New nurses are put on drug rounds in their first week	✗ não	discutir
New nurses are put on drug rounds in their first week	→	Allergy information is in a different system from the prescribing one	✗ não	discutir
Alerts in the system are so frequent that they are clicked through	→	Discharge medication lists disagree with the inpatient chart	✗ não	discutir
Near misses are not reported because the form takes twenty minutes	→	Patients are moved between wards mid-treatment and the chart lags behind	✗ não	discutir
Patients are moved between wards mid-treatment and the chart lags behind	→	Near misses are not reported because the form takes twenty minutes	✗ não	discutir
Errors are discussed as individual mistakes, not as patterns	→	The same look-alike drugs are stored next to each other	✗ não	discutir
Alerts in the system are so frequent that they are clicked through	→	Near misses are not reported because the form takes twenty minutes	✗ não	discutir
Patients are moved between wards mid-treatment and the chart lags behind	→	Double-checking is signed without a second person actually looking	✗ não	discutir
Allergy information is in a different system from the prescribing one	→	Double-checking is signed without a second person actually looking	✗ não	discutir
Discharge medication lists disagree with the inpatient chart	→	Double-checking is signed without a second person actually looking	✗ não	discutir
The same error recurs on the same drug every few months	→	The same look-alike drugs are stored next to each other	✗ não	discutir
The same error recurs on the same drug every few months	→	Errors are discussed as individual mistakes, not as patterns	✗ não	discutir
Allergy information is in a different system from the prescribing one	→	New nurses are put on drug rounds in their first week	✗ não	discutir
The same look-alike drugs are stored next to each other	→	Near misses are not reported because the form takes twenty minutes	✗ não	discutir
…	→	Infusion pumps on the ward come from three manufacturers	✗ não	discutir
Reporting an error has led to disciplinary action in the past	→	Handwritten charts are still used when the system is down, which is often	✗ não	discutir
Infusion pumps on the ward come from three manufacturers	→	…	✗ não	discutir
…	→	…	✗ não	discutir
Interruptions during the drug round are constant	→	Infusion pumps on the ward come from three manufacturers	✗ não	discutir
…	→	Handwritten charts are still used when the system is down, which is often	✗ não	discutir
…	→	Night shift has one nurse for the whole bay	✗ não	discutir
Weight-based doses are calculated by hand at the bedside	→	Infusion pumps on the ward come from three manufacturers	✗ não	discutir
Agency staff do not know the ward's conventions	→	…	✗ não	discutir
Weight-based doses are calculated by hand at the bedside	→	Night shift has one nurse for the whole bay	✗ não	discutir
Night shift has one nurse for the whole bay	→	Reporting an error has led to disciplinary action in the past	✗ não	discutir
Agency staff do not know the ward's conventions	→	Weight-based doses are calculated by hand at the bedside	✗ não	discutir
Interruptions during the drug round are constant	→	Agency staff do not know the ward's conventions	✗ não	discutir
Pharmacy reviews charts a day after the first dose was given	→	Handwritten charts are still used when the system is down, which is often	✗ não	discutir
Handwritten charts are still used when the system is down, which is often	→	Pharmacy reviews charts a day after the first dose was given	✗ não	discutir
Interruptions during the drug round are constant	→	…	✗ não	discutir
Agency staff do not know the ward's conventions	→	Handwritten charts are still used when the system is down, which is often	✗ não	discutir
…	→	Pharmacy reviews charts a day after the first dose was given	✗ não	discutir
Weight-based doses are calculated by hand at the bedside	→	Handwritten charts are still used when the system is down, which is often	✗ não	discutir
…	→	Night shift has one nurse for the whole bay	✗ não	discutir
Reporting an error has led to disciplinary action in the past	→	Agency staff do not know the ward's conventions	✗ não	discutir
Interruptions during the drug round are constant	→	Handwritten charts are still used when the system is down, which is often	✗ não	discutir
Agency staff do not know the ward's conventions	→	…	✗ não	discutir
Weight-based doses are calculated by hand at the bedside	→	Agency staff do not know the ward's conventions	✗ não	discutir
Agency staff do not know the ward's conventions	→	Infusion pumps on the ward come from three manufacturers	✗ não	discutir
Infusion pumps on the ward come from three manufacturers	→	Handwritten charts are still used when the system is down, which is often	✗ não	discutir
…	→	Interruptions during the drug round are constant	✗ não	discutir
Handwritten charts are still used when the system is down, which is often	→	Interruptions during the drug round are constant	✗ não	discutir
Agency staff do not know the ward's conventions	→	Pharmacy reviews charts a day after the first dose was given	✗ não	discutir
Handwritten charts are still used when the system is down, which is often	→	Agency staff do not know the ward's conventions	✗ não	discutir
Reporting an error has led to disciplinary action in the past	→	…	✗ não	discutir
Night shift has one nurse for the whole bay	→	…	✗ não	discutir
…	→	Handwritten charts are still used when the system is down, which is often	✗ não	discutir
Infusion pumps on the ward come from three manufacturers	→	Pharmacy reviews charts a day after the first dose was given	✗ não	discutir
Interruptions during the drug round are constant	→	Weight-based doses are calculated by hand at the bedside	✗ não	discutir
…	→	Weight-based doses are calculated by hand at the bedside	✗ não	discutir
Infusion pumps on the ward come from three manufacturers	→	…	✗ não	discutir
Infusion pumps on the ward come from three manufacturers	→	Interruptions during the drug round are constant	✗ não	discutir
Pharmacy reviews charts a day after the first dose was given	→	Interruptions during the drug round are constant	✗ não	discutir
Reporting an error has led to disciplinary action in the past	→	Weight-based doses are calculated by hand at the bedside	✗ não	discutir
Handwritten charts are still used when the system is down, which is often	→	…	✗ não	discutir
Weight-based doses are calculated by hand at the bedside	→	…	✗ não	discutir
Pharmacy reviews charts a day after the first dose was given	→	Weight-based doses are calculated by hand at the bedside	✗ não	discutir
…	→	Pharmacy reviews charts a day after the first dose was given	✗ não	discutir
Handwritten charts are still used when the system is down, which is often	→	…	✗ não	discutir
Interruptions during the drug round are constant	→	Night shift has one nurse for the whole bay	✗ não	discutir
Night shift has one nurse for the whole bay	→	…	✗ não	discutir
…	→	Reporting an error has led to disciplinary action in the past	✗ não	discutir
…	→	Weight-based doses are calculated by hand at the bedside	✗ não	discutir
…	→	…	✗ não	discutir
Handwritten charts are still used when the system is down, which is often	→	Reporting an error has led to disciplinary action in the past	✗ não	discutir
Pharmacy reviews charts a day after the first dose was given	→	…	✗ não	discutir
Agency staff do not know the ward's conventions	→	Reporting an error has led to disciplinary action in the past	✗ não	discutir
Reporting an error has led to disciplinary action in the past	→	Pharmacy reviews charts a day after the first dose was given	✗ não	discutir
Night shift has one nurse for the whole bay	→	Weight-based doses are calculated by hand at the bedside	✗ não	discutir
Weight-based doses are calculated by hand at the bedside	→	…	✗ não	discutir
Night shift has one nurse for the whole bay	→	Agency staff do not know the ward's conventions	✗ não	discutir
Agency staff do not know the ward's conventions	→	Night shift has one nurse for the whole bay	✗ não	discutir
Reporting an error has led to disciplinary action in the past	→	…	✗ não	discutir
Handwritten charts are still used when the system is down, which is often	→	Weight-based doses are calculated by hand at the bedside	✗ não	discutir
…	→	Interruptions during the drug round are constant	✗ não	discutir
Interruptions during the drug round are constant	→	Pharmacy reviews charts a day after the first dose was given	✗ não	discutir
Night shift has one nurse for the whole bay	→	Infusion pumps on the ward come from three manufacturers	✗ não	discutir
Interruptions during the drug round are constant	→	…	✗ não	discutir
Infusion pumps on the ward come from three manufacturers	→	Night shift has one nurse for the whole bay	✗ não	discutir
Handwritten charts are still used when the system is down, which is often	→	Night shift has one nurse for the whole bay	✗ não	discutir
…	→	Infusion pumps on the ward come from three manufacturers	✗ não	discutir
Pharmacy reviews charts a day after the first dose was given	→	…	✗ não	discutir
Weight-based doses are calculated by hand at the bedside	→	Interruptions during the drug round are constant	✗ não	discutir
Infusion pumps on the ward come from three manufacturers	→	Weight-based doses are calculated by hand at the bedside	✗ não	discutir
Night shift has one nurse for the whole bay	→	Pharmacy reviews charts a day after the first dose was given	✗ não	discutir
Reporting an error has led to disciplinary action in the past	→	Night shift has one nurse for the whole bay	✗ não	discutir
Pharmacy reviews charts a day after the first dose was given	→	Agency staff do not know the ward's conventions	✗ não	discutir
…	→	Agency staff do not know the ward's conventions	✗ não	discutir
Reporting an error has led to disciplinary action in the past	→	Infusion pumps on the ward come from three manufacturers	✗ não	discutir
Weight-based doses are calculated by hand at the bedside	→	Reporting an error has led to disciplinary action in the past	✗ não	discutir
Night shift has one nurse for the whole bay	→	Handwritten charts are still used when the system is down, which is often	✗ não	discutir
Infusion pumps on the ward come from three manufacturers	→	Reporting an error has led to disciplinary action in the past	✗ não	discutir
Weight-based doses are calculated by hand at the bedside	→	Pharmacy reviews charts a day after the first dose was given	✗ não	discutir
Pharmacy reviews charts a day after the first dose was given	→	Reporting an error has led to disciplinary action in the past	✗ não	discutir
…	→	Reporting an error has led to disciplinary action in the past	✗ não	discutir
Interruptions during the drug round are constant	→	Reporting an error has led to disciplinary action in the past	✗ não	discutir
Reporting an error has led to disciplinary action in the past	→	Interruptions during the drug round are constant	✗ não	discutir