THE QUESTION
Why do medication errors keep happening?
Propose what to do, then judge whether each action would move each root.
Sealed 23 days ago: this room no longer knows who sat in it; only its steward is still named. What it concluded stays.
30 at the table (29 simulated) · 3 actions proposed against 6 root causes. Add one, then judge whether each action moves each cause.
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PROPOSED ACTION
A near-miss report that takes two minutes and never names a person
Nothing said yet.
Score the roots first
why
The method's own practice, before any action is proposed: each root cause is scored 1–5 on how feasible it is to address, how much impact addressing it would have, and how likely it is to resolve by itself with no intervention. Priority goes to roots with high impact, high feasibility and low likelihood of fixing themselves — priority = impact + feasibility − likelihood. Scores are averaged across the group and shown with how many scored.
1 = low, 5 = high. Your own scores; the group's averages beside them.
| root cause | feasible | impact | fixes itself | priority |
|---|---|---|---|---|
| Errors are discussed as individual mistakes, not as patterns | – | – | – | – |
| Double-checking is signed without a second person actually looking | – | – | – | – |
| Handwritten charts are still used when the system is down, which is often | – | – | – | – |
| Pharmacy reviews charts a day after the first dose was given | – | – | – | – |
| Allergy information is in a different system from the prescribing one | – | – | – | – |
| Near misses are not reported because the form takes twenty minutes | – | – | – | – |
Would each action move each root cause?
Down the side: the actions people proposed. Across the top: the root causes the map found. Every square is one vote on one question — would this action significantly reduce that cause? One side has to reach 75% of the votes cast to settle it; short of that the square stays split. Each square shows how its votes fell — yes / worse / no — and a square is settled when one of those reaches three quarters of them.
why
Answered at 75% of votes cast, like every other question here. Split means people voted and neither side reached that bar — it is a result, not a queue, and it stays split until enough people change their minds. A square nobody settles stays undecided; it never turns into a no. Judging each pair on its own is what stops a popular action being credited with fixing things it does not touch.
| ACTION | ROOT CAUSES · does the action on the left reduce it? | |||||
|---|---|---|---|---|---|---|
| Errors are discussed as individual mistakes, not as patterns | Double-checking is signed without a second person actually looking | Handwritten charts are still used when the system is down, which is often | Pharmacy reviews charts a day after the first dose was given | Allergy information is in a different system from the prescribing one | Near misses are not reported because the form takes twenty minutes | |
| Staff nights by acuity score, not by bed count discuss | ✗ no, it does not 4 yes / 0 worse / 25 no | ✗ no, it does not 3 yes / 0 worse / 26 no | ✗ no, it does not 2 yes / 0 worse / 27 no | ⚑ the group split 8 yes / 0 worse / 21 no | ✗ no, it does not 3 yes / 0 worse / 26 no | not decided yet |
| A near-miss report that takes two minutes and never names a person in focus ↑ · close ✕ | ✗ no, it does not 2 yes / 0 worse / 27 no | ✗ no, it does not 3 yes / 0 worse / 26 no | ⚑ the group split 8 yes / 0 worse / 21 no | ✗ no, it does not 3 yes / 0 worse / 26 no | ✗ no, it does not 4 yes / 0 worse / 25 no | not decided yet |
| Protected drug rounds: a tabard and a rule that only a patient emergency interrupts discuss | ✗ no, it does not 7 yes / 0 worse / 22 no | ✗ no, it does not 6 yes / 0 worse / 23 no | ✓ yes, it reduces this 27 yes / 0 worse / 2 no | ✗ no, it does not 5 yes / 0 worse / 24 no | ✗ no, it does not 7 yes / 0 worse / 22 no | not decided yet |
Highest leverage so far
Protected drug rounds: a tabard and a rule that only a patient emergency interrupts reduces 1 of 6 root causes
THE ACTIONS ON THE MAP
Showing every action the room judged: it acts directly on 1 of the 6 root causes. It does not act directly on 5.
Read from the squares the room settled at Actions, nothing else. A root in green is reduced by at least one of the shown actions; in grey, none of them acts on it directly; a red outline means one of them makes it worse.
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Each number on the map marks a root cause that action reduces.
① Staff nights by acuity score, not by bed count
② A near-miss report that takes two minutes and never names a person
③ Protected drug rounds: a tabard and a rule that only a patient emergency interrupts
What we expect to follow
Predictions about the actions: what each should change, how to measure it, and when to check. On the date, someone who was in the room writes what actually happened beside it.
why
A map says which actions move which causes. It does not say whether anyone did them, or whether anything changed. An entry here is a prediction with a date and something to measure, written after the map settled. When the date comes, what actually happened is written beside it and the prediction stays as it was: a wrong one is the useful kind. Nobody voted on any of this and it changes nothing the room found.
due 24 Mar 2027
actionStaff nights by acuity score, not by bed count
we expectfewer errors once the drug round cannot be interrupted
measured bymedication errors reported per 1,000 doses
guessesthe room: 3 (median of 15, spread 1.8 to 4.8)