问题
Why do medication errors keep happening?
把你的贴纸用在最重要的内容上。有证据支持的想法可以占用一个保留席位。
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你的贴纸额度
每个想法最多一张，共 5 张。至少投一票。
有 5 个席位为被忽视的想法保留——附上链接提名一个，当 2 人认同来源相关时就会计入。
为什么
阶段结束时，一名被提名者通过随机抽签入选，其余按提名数入选，每个利益相关方类别最多一个。模型只检查页面是否关于同一主题——从不检查它是否证明了这个主张。那要由房间来判断；没有其他人支持的提名不能占用席位。
类别 1
Allergy information is in a different system from the prescribing one
3 票讨论
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.
2 票讨论
类别 2
Infusion pumps on the ward come from three manufacturers
5 票讨论
The same look-alike drugs are stored next to each other
5 票讨论
类别 3
Near misses are not reported because the form takes twenty minutes
7 票讨论
Reporting an error has led to disciplinary action in the past
3 票讨论
类别 4
Handwritten charts are still used when the system is down, which is often
9 票讨论
The electronic chart times out and loses the entry
2 票讨论
类别 5
Verbal orders are accepted over the phone without read-back
0 票讨论
Double-checking is signed without a second person actually looking
Meaning the recurring pattern, not the one incident under review.
未归类
Pharmacy reviews charts a day after the first dose was given
3 票讨论
The ward manager spends most of the shift covering gaps in the rota
2 票讨论
Errors are discussed as individual mistakes, not as patterns
To be precise: this is about the system, not any nurse or doctor.
8 票讨论
The same error recurs on the same drug every few months
Meaning the recurring pattern, not the one incident under review.
5 票讨论
Nurses are measured on completing the round on time
2 票讨论
Staffing is set by bed count, not by how sick the patients are
0 票讨论
Agency staff do not know the ward's conventions
14 票讨论
Patients are moved between wards mid-treatment and the chart lags behind
2 票讨论
New nurses are put on drug rounds in their first week
2 票讨论
The drug trolley is shared between two bays
0 票讨论
Discharge medication lists disagree with the inpatient chart
13 票讨论
Nobody looks at the error reports together
1 票讨论
Night shift has one nurse for the whole bay
9 票讨论
Prescriptions are written in the corridor between other tasks
1 票讨论
Interruptions during the drug round are constant
9 票讨论
Alerts in the system are so frequent that they are clicked through
Scope: this ward on this site, not the trust as a whole.
15 票讨论
Doctors change doses verbally on the round and the chart is updated later
Meaning the recurring pattern, not the one incident under review.
0 票讨论中（1）