SPØRSMÅLET
Why do medication errors keep happening?
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Klistremerkene dine
Ett per idé, 5 totalt. Minst én stemme.
Reserverte plasser for oversette idéer: 5 — nominer én med en lenke, og den teller når 2 personer er enige om at kilden er relevant.
hvorfor
Når fasen stenger, kommer én nominert inn ved loddtrekning og resten etter antall nominasjoner, høyst én per interessentklasse. En modell sjekker bare om siden handler om samme emne — aldri om den beviser påstanden. Den vurderingen er rommets, og en nominasjon ingen andre står bak, får ingen plass.
New nurses are put on drug rounds in their first week
Ingenting sagt ennå.
KLYNGE 1
Allergy information is in a different system from the prescribing one
stemmer: 3diskuter
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.
stemmer: 2diskuter
KLYNGE 2
Infusion pumps on the ward come from three manufacturers
stemmer: 5diskuter
The same look-alike drugs are stored next to each other
stemmer: 5diskuter
KLYNGE 3
Near misses are not reported because the form takes twenty minutes
stemmer: 7diskuter
Reporting an error has led to disciplinary action in the past
stemmer: 3diskuter
KLYNGE 4
Handwritten charts are still used when the system is down, which is often
stemmer: 9diskuter
The electronic chart times out and loses the entry
stemmer: 2diskuter
KLYNGE 5
Verbal orders are accepted over the phone without read-back
stemmer: 0diskuter
Double-checking is signed without a second person actually looking
Meaning the recurring pattern, not the one incident under review.
stemmer: 9
↳ nominert til en plass: https://example.org/ops-incident-review.pdf could not read it (HTTPError) 1 av 2 står bak
diskuterIKKE I EN KLYNGE
Pharmacy reviews charts a day after the first dose was given
stemmer: 3diskuter
The ward manager spends most of the shift covering gaps in the rota
stemmer: 2diskuter
Errors are discussed as individual mistakes, not as patterns
To be precise: this is about the system, not any nurse or doctor.
stemmer: 8diskuter
The same error recurs on the same drug every few months
Meaning the recurring pattern, not the one incident under review.
stemmer: 5diskuter
Nurses are measured on completing the round on time
stemmer: 2diskuter
Staffing is set by bed count, not by how sick the patients are
stemmer: 0diskuter
Agency staff do not know the ward's conventions
stemmer: 14diskuter
Patients are moved between wards mid-treatment and the chart lags behind
stemmer: 2diskuter
The drug trolley is shared between two bays
stemmer: 0diskuter
Discharge medication lists disagree with the inpatient chart
stemmer: 13diskuter
Nobody looks at the error reports together
stemmer: 1diskuter
Night shift has one nurse for the whole bay
stemmer: 9diskuter
Prescriptions are written in the corridor between other tasks
stemmer: 1diskuter
Interruptions during the drug round are constant
stemmer: 9diskuter
Alerts in the system are so frequent that they are clicked through
Scope: this ward on this site, not the trust as a whole.
stemmer: 15diskuter
Weight-based doses are calculated by hand at the bedside
stemmer: 5diskuter
Doctors change doses verbally on the round and the chart is updated later
Meaning the recurring pattern, not the one incident under review.
stemmer: 0diskusjon (1)