PITANJE
Why do medication errors keep happening?
Potrošite nalepnice na ono što je najvažnije. Ideja sa dokazom može da zauzme rezervisano mesto.
zatvoreno · nazad na fazu Akcije
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Vaš broj nalepnica
Jedna po ideji, ukupno 5. Najmanje jedan glas.
Rezervisana mesta za previđene ideje: 5 — nominujte jednu uz link, i ona se računa kada se dovoljno ljudi (2) složi da je izvor relevantan.
zašto
Kada se faza zatvori, jedan nominovani ulazi slučajnim izvlačenjem, a ostali po broju nominacija, najviše jedan po klasi zainteresovanih strana. Model proverava samo da li stranica govori o istoj temi — nikad da li dokazuje tvrdnju. Ta procena pripada sobi, a nominacija iza koje niko drugi ne stoji ne dobija mesto.
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.
klaster 1
Još ništa nije rečeno.
KLASTER 1
Allergy information is in a different system from the prescribing one
glasova: 3diskutuj
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.
glasova: 2u fokusu ↑ · zatvori ✕
KLASTER 2
Infusion pumps on the ward come from three manufacturers
glasova: 5diskutuj
The same look-alike drugs are stored next to each other
glasova: 5diskutuj
KLASTER 3
Near misses are not reported because the form takes twenty minutes
glasova: 7diskutuj
Reporting an error has led to disciplinary action in the past
glasova: 3diskutuj
KLASTER 4
Handwritten charts are still used when the system is down, which is often
glasova: 9diskutuj
The electronic chart times out and loses the entry
glasova: 2diskutuj
KLASTER 5
Verbal orders are accepted over the phone without read-back
glasova: 0diskutuj
Double-checking is signed without a second person actually looking
Meaning the recurring pattern, not the one incident under review.
glasova: 9
↳ nominovano za rezervisano mesto: https://example.org/ops-incident-review.pdf could not read it (HTTPError) podrška: 1 od 2
diskutujVAN KLASTERA
Pharmacy reviews charts a day after the first dose was given
glasova: 3diskutuj
The ward manager spends most of the shift covering gaps in the rota
glasova: 2diskutuj
Errors are discussed as individual mistakes, not as patterns
To be precise: this is about the system, not any nurse or doctor.
glasova: 8diskutuj
The same error recurs on the same drug every few months
Meaning the recurring pattern, not the one incident under review.
glasova: 5diskutuj
Nurses are measured on completing the round on time
glasova: 2diskutuj
Staffing is set by bed count, not by how sick the patients are
glasova: 0diskutuj
Agency staff do not know the ward's conventions
glasova: 14diskutuj
Patients are moved between wards mid-treatment and the chart lags behind
glasova: 2diskutuj
New nurses are put on drug rounds in their first week
glasova: 2diskutuj
The drug trolley is shared between two bays
glasova: 0diskutuj
Discharge medication lists disagree with the inpatient chart
glasova: 13diskutuj
Nobody looks at the error reports together
glasova: 1diskutuj
Night shift has one nurse for the whole bay
glasova: 9diskutuj
Prescriptions are written in the corridor between other tasks
glasova: 1diskutuj
Interruptions during the drug round are constant
glasova: 9diskutuj
Alerts in the system are so frequent that they are clicked through
Scope: this ward on this site, not the trust as a whole.
glasova: 15diskutuj
Weight-based doses are calculated by hand at the bedside
glasova: 5diskutuj
Doctors change doses verbally on the round and the chart is updated later
Meaning the recurring pattern, not the one incident under review.
glasova: 0diskusija (1)