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