PERTANYAANNYA
Why do medication errors keep happening?
Kelompokkan kartu yang menurut Anda mirip. Klaster membantu membaca; klaster tidak memutuskan apa pun.
ditutup · kembali ke tahap Tindakan
Melihat sebagai tamu. Masukkan nama pengguna untuk bergabung dan ikut serta.
Klaster terbentuk dari kemiripan, nama datang terakhir
Urutan baku: kaitkan pasangan gagasan yang menurut Anda mirip — kaitan bersifat simetris (A~B sama dengan B~A; arah tidak pernah berpengaruh) dan sebuah kaitan berlaku setelah dibuat oleh 2 anggota.
mengapa
Kaitan bersifat simetris — A~B sama dengan B~A. Klaster adalah kumpulan yang muncul dari kaitan yang berlaku, dan hanya klaster yang sudah terbentuk yang bisa diberi nama, oleh seseorang. Kaitan Anda sendiri diberi ✕ untuk menariknya; Anda tidak bisa menghapus kaitan orang lain. Klaster menata dinding dan tidak pernah membatasi pemberian suara — dua kartu yang menyatakan KLAIM yang sama digabungkan, dan itu dilakukan di tahap Penjelasan.
Kaitan dan nama dibuat selama tahap Pengelompokan berjalan; tombol ← milik pemandu membukanya kembali.
Verbal orders are accepted over the phone without read-back
klaster 5
Belum ada yang berbicara.
klaster tanpa nama — beri nama jika kelompok melihat benang merahnya, atau biarkan tanpa nama (2)
Handwritten charts are still used when the system is down, which is often
~ The electronic chart …The electronic chart times out and loses the entry (20)
The electronic chart times out and loses the entry
~ Handwritten charts ar…Handwritten charts are still used when the system is down, which is often (20)
klaster tanpa nama — beri nama jika kelompok melihat benang merahnya, atau biarkan tanpa nama (2)
Verbal orders are accepted over the phone without read-back
Double-checking is signed without a second person actually looking
~ Verbal orders are acc…Verbal orders are accepted over the phone without read-back (16)
klaster tanpa nama — beri nama jika kelompok melihat benang merahnya, atau biarkan tanpa nama (2)
The same look-alike drugs are stored next to each other
~ Infusion pumps on the…Infusion pumps on the ward come from three manufacturers (9)
Infusion pumps on the ward come from three manufacturers
~ The same look-alike d…The same look-alike drugs are stored next to each other (9)
klaster tanpa nama — beri nama jika kelompok melihat benang merahnya, atau biarkan tanpa nama (2)
Allergy information is in a different system from the prescribing one
~ Training on the presc…Training on the prescribing system was a one-hour session two years ago (17)
Training on the prescribing system was a one-hour session two years ago
~ Allergy information i…Allergy information is in a different system from the prescribing one (17)
klaster tanpa nama — beri nama jika kelompok melihat benang merahnya, atau biarkan tanpa nama (2)
Near misses are not reported because the form takes twenty minutes
~ Reporting an error ha…Reporting an error has led to disciplinary action in the past (19)
Reporting an error has led to disciplinary action in the past
~ Near misses are not r…Near misses are not reported because the form takes twenty minutes (19)
· belum masuk klaster (18)
Pharmacy reviews charts a day after the first dose was given
The ward manager spends most of the shift covering gaps in the rota
Errors are discussed as individual mistakes, not as patterns
The same error recurs on the same drug every few months
Nurses are measured on completing the round on time
Staffing is set by bed count, not by how sick the patients are
Agency staff do not know the ward's conventions
Patients are moved between wards mid-treatment and the chart lags behind
New nurses are put on drug rounds in their first week
The drug trolley is shared between two bays
Discharge medication lists disagree with the inpatient chart
Nobody looks at the error reports together
Night shift has one nurse for the whole bay
Prescriptions are written in the corridor between other tasks
Interruptions during the drug round are constant
Alerts in the system are so frequent that they are clicked through
Weight-based doses are calculated by hand at the bedside
Doctors change doses verbally on the round and the chart is updated later