THE QUESTION
Why do medication errors keep happening?
The root causes, deepest first. Disagreements stay on the map.
closed · back to Actions
Viewing as guest. Enter a handle to join and take part.
The map
Root causes on the left, outlined in green. Tap a claim to see its chain.
a link the room certified contested: the room could not settle it
Every claim on this map, with its own address (15)
Each page says what the room certified around the claim, with the counts, and can be cited, embedded, or read as JSON.
FOUND BY THIS ROOM · 12
| Allergy information is in a different system from the prescribing one | → | Alerts in the system are so frequent that they are clicked through |
| → | The same look-alike drugs are stored next to each other | |
| Double-checking is signed without a second person actually looking | → | Patients are moved between wards mid-treatment and the chart lags behi |
| → | Discharge medication lists disagree with the inpatient chart | |
| Errors are discussed as individual mistakes, not as patterns | → | Near misses are not reported because the form takes twenty minutes |
| → | The same error recurs on the same drug every few months | |
| Handwritten charts are still used when the system is down, which is of | → | Infusion pumps on the ward come from three manufacturers |
| Pharmacy reviews charts a day after the first dose was given | → | Night shift has one nurse for the whole bay |
| Infusion pumps on the ward come from three manufacturers | → | Agency staff do not know the ward's conventions |
| Near misses are not reported because the form takes twenty minutes | → | The same look-alike drugs are stored next to each other |
| Night shift has one nurse for the whole bay | → | Interruptions during the drug round are constant |
| Patients are moved between wards mid-treatment and the chart lags behi | → | Discharge medication lists disagree with the inpatient chart |