True Causes
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Why do medication errors keep happening?
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Logic → · record
THE QUESTION

Why do medication errors keep happening?

Does one influence the other? Three quarters of the votes cast decide.

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176 / 180 settled 0 for you to answer
Last tally: 176 decided · 1 escalated to cross-group panels · 0 contested · 3 below quorum — panels need at least max(2, 75% of panel) votes cast; your smallest panel has 15 members.
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Interruptions during the drug round are constant → influences? → Handwritten charts are still used when the system is down, which is often
Nothing said yet.
Completed phase — the record of pairs and votes stands above.Logic sidecar ↗
Patients are moved between wards mid-treatment and the chart lags behind→Errors are discussed as individual mistakes, not as patternsopendiscuss
…→Agency staff do not know the ward's conventionsopendiscuss
Pharmacy reviews charts a day after the first dose was given→Infusion pumps on the ward come from three manufacturersopendiscuss
Agency staff do not know the ward's conventions→Interruptions during the drug round are constantopen escalateddiscuss
Allergy information is in a different system from the prescribing one→The same look-alike drugs are stored next to each other✓ yesdiscuss
Allergy information is in a different system from the prescribing one→Alerts in the system are so frequent that they are clicked through✓ yesdiscuss
Patients are moved between wards mid-treatment and the chart lags behind→Discharge medication lists disagree with the inpatient chart✓ yesdiscuss
Near misses are not reported because the form takes twenty minutes→The same look-alike drugs are stored next to each other✓ yesdiscuss
Double-checking is signed without a second person actually looking→Patients are moved between wards mid-treatment and the chart lags behind✓ yesdiscuss
Errors are discussed as individual mistakes, not as patterns→The same error recurs on the same drug every few months✓ yesdiscuss
Errors are discussed as individual mistakes, not as patterns→Near misses are not reported because the form takes twenty minutes✓ yesdiscuss
Night shift has one nurse for the whole bay→Interruptions during the drug round are constant✓ yesdiscuss
Pharmacy reviews charts a day after the first dose was given→Night shift has one nurse for the whole bay✓ yesdiscuss
Infusion pumps on the ward come from three manufacturers→Agency staff do not know the ward's conventions✓ yesdiscuss
Handwritten charts are still used when the system is down, which is often→Infusion pumps on the ward come from three manufacturers✓ yesdiscuss
Double-checking is signed without a second person actually looking→Discharge medication lists disagree with the inpatient chart✓ inferreddiscuss
Double-checking is signed without a second person actually looking→Allergy information is in a different system from the prescribing one✗ nodiscuss
New nurses are put on drug rounds in their first week→The same error recurs on the same drug every few months✗ nodiscuss
The same look-alike drugs are stored next to each other→Double-checking is signed without a second person actually looking✗ nodiscuss
Discharge medication lists disagree with the inpatient chart→Allergy information is in a different system from the prescribing one✗ nodiscuss
The same look-alike drugs are stored next to each other→The same error recurs on the same drug every few months✗ nodiscuss
Alerts in the system are so frequent that they are clicked through→New nurses are put on drug rounds in their first week✗ nodiscuss
Discharge medication lists disagree with the inpatient chart→Near misses are not reported because the form takes twenty minutes✗ nodiscuss
Double-checking is signed without a second person actually looking→Alerts in the system are so frequent that they are clicked through✗ nodiscuss
Errors are discussed as individual mistakes, not as patterns→Patients are moved between wards mid-treatment and the chart lags behind✗ nodiscuss
Alerts in the system are so frequent that they are clicked through→The same error recurs on the same drug every few months✗ nodiscuss
The same error recurs on the same drug every few months→Patients are moved between wards mid-treatment and the chart lags behind✗ nodiscuss
Allergy information is in a different system from the prescribing one→Discharge medication lists disagree with the inpatient chart✗ nodiscuss
Discharge medication lists disagree with the inpatient chart→Patients are moved between wards mid-treatment and the chart lags behind✗ nodiscuss
The same error recurs on the same drug every few months→New nurses are put on drug rounds in their first week✗ nodiscuss
Errors are discussed as individual mistakes, not as patterns→Discharge medication lists disagree with the inpatient chart✗ nodiscuss
Discharge medication lists disagree with the inpatient chart→The same look-alike drugs are stored next to each other✗ nodiscuss
The same error recurs on the same drug every few months→Double-checking is signed without a second person actually looking✗ nodiscuss
The same error recurs on the same drug every few months→Alerts in the system are so frequent that they are clicked through✗ nodiscuss
The same error recurs on the same drug every few months→Allergy information is in a different system from the prescribing one✗ nodiscuss
The same look-alike drugs are stored next to each other→New nurses are put on drug rounds in their first week✗ nodiscuss
Near misses are not reported because the form takes twenty minutes→The same error recurs on the same drug every few months✗ nodiscuss
Near misses are not reported because the form takes twenty minutes→Errors are discussed as individual mistakes, not as patterns✗ nodiscuss
The same look-alike drugs are stored next to each other→Discharge medication lists disagree with the inpatient chart✗ nodiscuss
Errors are discussed as individual mistakes, not as patterns→Double-checking is signed without a second person actually looking✗ nodiscuss
Alerts in the system are so frequent that they are clicked through→Double-checking is signed without a second person actually looking✗ nodiscuss
Discharge medication lists disagree with the inpatient chart→Alerts in the system are so frequent that they are clicked through✗ nodiscuss
The same error recurs on the same drug every few months→Near misses are not reported because the form takes twenty minutes✗ nodiscuss
Double-checking is signed without a second person actually looking→The same error recurs on the same drug every few months✗ nodiscuss
New nurses are put on drug rounds in their first week→Patients are moved between wards mid-treatment and the chart lags behind✗ nodiscuss
Errors are discussed as individual mistakes, not as patterns→Alerts in the system are so frequent that they are clicked through✗ nodiscuss
The same look-alike drugs are stored next to each other→Patients are moved between wards mid-treatment and the chart lags behind✗ nodiscuss
The same look-alike drugs are stored next to each other→Alerts in the system are so frequent that they are clicked through✗ nodiscuss
New nurses are put on drug rounds in their first week→Discharge medication lists disagree with the inpatient chart✗ nodiscuss
Near misses are not reported because the form takes twenty minutes→Allergy information is in a different system from the prescribing one✗ nodiscuss
New nurses are put on drug rounds in their first week→Near misses are not reported because the form takes twenty minutes✗ nodiscuss
Double-checking is signed without a second person actually looking→Near misses are not reported because the form takes twenty minutes✗ nodiscuss
The same look-alike drugs are stored next to each other→Errors are discussed as individual mistakes, not as patterns✗ nodiscuss
Near misses are not reported because the form takes twenty minutes→Alerts in the system are so frequent that they are clicked through✗ nodiscuss
Errors are discussed as individual mistakes, not as patterns→Allergy information is in a different system from the prescribing one✗ nodiscuss
Patients are moved between wards mid-treatment and the chart lags behind→The same error recurs on the same drug every few months✗ nodiscuss
New nurses are put on drug rounds in their first week→Alerts in the system are so frequent that they are clicked through✗ nodiscuss
Double-checking is signed without a second person actually looking→The same look-alike drugs are stored next to each other✗ nodiscuss
The same error recurs on the same drug every few months→Discharge medication lists disagree with the inpatient chart✗ nodiscuss
The same look-alike drugs are stored next to each other→Allergy information is in a different system from the prescribing one✗ nodiscuss
Double-checking is signed without a second person actually looking→Errors are discussed as individual mistakes, not as patterns✗ nodiscuss
Near misses are not reported because the form takes twenty minutes→Discharge medication lists disagree with the inpatient chart✗ nodiscuss
Patients are moved between wards mid-treatment and the chart lags behind→The same look-alike drugs are stored next to each other✗ nodiscuss
Allergy information is in a different system from the prescribing one→Near misses are not reported because the form takes twenty minutes✗ nodiscuss
Discharge medication lists disagree with the inpatient chart→Errors are discussed as individual mistakes, not as patterns✗ nodiscuss
Allergy information is in a different system from the prescribing one→Errors are discussed as individual mistakes, not as patterns✗ nodiscuss
Discharge medication lists disagree with the inpatient chart→The same error recurs on the same drug every few months✗ nodiscuss
Patients are moved between wards mid-treatment and the chart lags behind→Allergy information is in a different system from the prescribing one✗ nodiscuss
Allergy information is in a different system from the prescribing one→Patients are moved between wards mid-treatment and the chart lags behind✗ nodiscuss
New nurses are put on drug rounds in their first week→Double-checking is signed without a second person actually looking✗ nodiscuss
Patients are moved between wards mid-treatment and the chart lags behind→New nurses are put on drug rounds in their first week✗ nodiscuss
Alerts in the system are so frequent that they are clicked through→Allergy information is in a different system from the prescribing one✗ nodiscuss
Errors are discussed as individual mistakes, not as patterns→New nurses are put on drug rounds in their first week✗ nodiscuss
Near misses are not reported because the form takes twenty minutes→New nurses are put on drug rounds in their first week✗ nodiscuss
New nurses are put on drug rounds in their first week→The same look-alike drugs are stored next to each other✗ nodiscuss
Alerts in the system are so frequent that they are clicked through→The same look-alike drugs are stored next to each other✗ nodiscuss
Patients are moved between wards mid-treatment and the chart lags behind→Alerts in the system are so frequent that they are clicked through✗ nodiscuss
Allergy information is in a different system from the prescribing one→The same error recurs on the same drug every few months✗ nodiscuss
Double-checking is signed without a second person actually looking→New nurses are put on drug rounds in their first week✗ nodiscuss
New nurses are put on drug rounds in their first week→Errors are discussed as individual mistakes, not as patterns✗ nodiscuss
Near misses are not reported because the form takes twenty minutes→Double-checking is signed without a second person actually looking✗ nodiscuss
Alerts in the system are so frequent that they are clicked through→Patients are moved between wards mid-treatment and the chart lags behind✗ nodiscuss
Alerts in the system are so frequent that they are clicked through→Errors are discussed as individual mistakes, not as patterns✗ nodiscuss
Discharge medication lists disagree with the inpatient chart→New nurses are put on drug rounds in their first week✗ nodiscuss
New nurses are put on drug rounds in their first week→Allergy information is in a different system from the prescribing one✗ nodiscuss
Alerts in the system are so frequent that they are clicked through→Discharge medication lists disagree with the inpatient chart✗ nodiscuss
Near misses are not reported because the form takes twenty minutes→Patients are moved between wards mid-treatment and the chart lags behind✗ nodiscuss
Patients are moved between wards mid-treatment and the chart lags behind→Near misses are not reported because the form takes twenty minutes✗ nodiscuss
Errors are discussed as individual mistakes, not as patterns→The same look-alike drugs are stored next to each other✗ nodiscuss
Alerts in the system are so frequent that they are clicked through→Near misses are not reported because the form takes twenty minutes✗ nodiscuss
Patients are moved between wards mid-treatment and the chart lags behind→Double-checking is signed without a second person actually looking✗ nodiscuss
Allergy information is in a different system from the prescribing one→Double-checking is signed without a second person actually looking✗ nodiscuss
Discharge medication lists disagree with the inpatient chart→Double-checking is signed without a second person actually looking✗ nodiscuss
The same error recurs on the same drug every few months→The same look-alike drugs are stored next to each other✗ nodiscuss
The same error recurs on the same drug every few months→Errors are discussed as individual mistakes, not as patterns✗ nodiscuss
Allergy information is in a different system from the prescribing one→New nurses are put on drug rounds in their first week✗ nodiscuss
The same look-alike drugs are stored next to each other→Near misses are not reported because the form takes twenty minutes✗ nodiscuss
…→Infusion pumps on the ward come from three manufacturers✗ nodiscuss
Reporting an error has led to disciplinary action in the past→Handwritten charts are still used when the system is down, which is often✗ nodiscuss
Infusion pumps on the ward come from three manufacturers→…✗ nodiscuss
…→…✗ nodiscuss
Interruptions during the drug round are constant→Infusion pumps on the ward come from three manufacturers✗ nodiscuss
…→Handwritten charts are still used when the system is down, which is often✗ nodiscuss
…→Night shift has one nurse for the whole bay✗ nodiscuss
Weight-based doses are calculated by hand at the bedside→Infusion pumps on the ward come from three manufacturers✗ nodiscuss
Agency staff do not know the ward's conventions→…✗ nodiscuss
Weight-based doses are calculated by hand at the bedside→Night shift has one nurse for the whole bay✗ nodiscuss
Night shift has one nurse for the whole bay→Reporting an error has led to disciplinary action in the past✗ nodiscuss
Agency staff do not know the ward's conventions→Weight-based doses are calculated by hand at the bedside✗ nodiscuss
Interruptions during the drug round are constant→Agency staff do not know the ward's conventions✗ nodiscuss
Pharmacy reviews charts a day after the first dose was given→Handwritten charts are still used when the system is down, which is often✗ nodiscuss
Handwritten charts are still used when the system is down, which is often→Pharmacy reviews charts a day after the first dose was given✗ nodiscuss
Interruptions during the drug round are constant→…✗ nodiscuss
Agency staff do not know the ward's conventions→Handwritten charts are still used when the system is down, which is often✗ nodiscuss
…→Pharmacy reviews charts a day after the first dose was given✗ nodiscuss
Weight-based doses are calculated by hand at the bedside→Handwritten charts are still used when the system is down, which is often✗ nodiscuss
…→Night shift has one nurse for the whole bay✗ nodiscuss
Reporting an error has led to disciplinary action in the past→Agency staff do not know the ward's conventions✗ nodiscuss
Interruptions during the drug round are constant→Handwritten charts are still used when the system is down, which is often✗ noin focus ↑ · close ✕
Agency staff do not know the ward's conventions→…✗ nodiscuss
Weight-based doses are calculated by hand at the bedside→Agency staff do not know the ward's conventions✗ nodiscuss
Agency staff do not know the ward's conventions→Infusion pumps on the ward come from three manufacturers✗ nodiscuss
Infusion pumps on the ward come from three manufacturers→Handwritten charts are still used when the system is down, which is often✗ nodiscuss
…→Interruptions during the drug round are constant✗ nodiscuss
Handwritten charts are still used when the system is down, which is often→Interruptions during the drug round are constant✗ nodiscuss
Agency staff do not know the ward's conventions→Pharmacy reviews charts a day after the first dose was given✗ nodiscuss
Handwritten charts are still used when the system is down, which is often→Agency staff do not know the ward's conventions✗ nodiscuss
Reporting an error has led to disciplinary action in the past→…✗ nodiscuss
Night shift has one nurse for the whole bay→…✗ nodiscuss
…→Handwritten charts are still used when the system is down, which is often✗ nodiscuss
Infusion pumps on the ward come from three manufacturers→Pharmacy reviews charts a day after the first dose was given✗ nodiscuss
Interruptions during the drug round are constant→Weight-based doses are calculated by hand at the bedside✗ nodiscuss
…→Weight-based doses are calculated by hand at the bedside✗ nodiscuss
Infusion pumps on the ward come from three manufacturers→…✗ nodiscuss
Infusion pumps on the ward come from three manufacturers→Interruptions during the drug round are constant✗ nodiscuss
Pharmacy reviews charts a day after the first dose was given→Interruptions during the drug round are constant✗ nodiscuss
Reporting an error has led to disciplinary action in the past→Weight-based doses are calculated by hand at the bedside✗ nodiscuss
Handwritten charts are still used when the system is down, which is often→…✗ nodiscuss
Weight-based doses are calculated by hand at the bedside→…✗ nodiscuss
Pharmacy reviews charts a day after the first dose was given→Weight-based doses are calculated by hand at the bedside✗ nodiscuss
…→Pharmacy reviews charts a day after the first dose was given✗ nodiscuss
Handwritten charts are still used when the system is down, which is often→…✗ nodiscuss
Interruptions during the drug round are constant→Night shift has one nurse for the whole bay✗ nodiscuss
Night shift has one nurse for the whole bay→…✗ nodiscuss
…→Reporting an error has led to disciplinary action in the past✗ nodiscuss
…→Weight-based doses are calculated by hand at the bedside✗ nodiscuss
…→…✗ nodiscuss
Handwritten charts are still used when the system is down, which is often→Reporting an error has led to disciplinary action in the past✗ nodiscuss
Pharmacy reviews charts a day after the first dose was given→…✗ nodiscuss
Agency staff do not know the ward's conventions→Reporting an error has led to disciplinary action in the past✗ nodiscuss
Reporting an error has led to disciplinary action in the past→Pharmacy reviews charts a day after the first dose was given✗ nodiscuss
Night shift has one nurse for the whole bay→Weight-based doses are calculated by hand at the bedside✗ nodiscuss
Weight-based doses are calculated by hand at the bedside→…✗ nodiscuss
Night shift has one nurse for the whole bay→Agency staff do not know the ward's conventions✗ nodiscuss
Agency staff do not know the ward's conventions→Night shift has one nurse for the whole bay✗ nodiscuss
Reporting an error has led to disciplinary action in the past→…✗ nodiscuss
Handwritten charts are still used when the system is down, which is often→Weight-based doses are calculated by hand at the bedside✗ nodiscuss
…→Interruptions during the drug round are constant✗ nodiscuss
Interruptions during the drug round are constant→Pharmacy reviews charts a day after the first dose was given✗ nodiscuss
Night shift has one nurse for the whole bay→Infusion pumps on the ward come from three manufacturers✗ nodiscuss
Interruptions during the drug round are constant→…✗ nodiscuss
Infusion pumps on the ward come from three manufacturers→Night shift has one nurse for the whole bay✗ nodiscuss
Handwritten charts are still used when the system is down, which is often→Night shift has one nurse for the whole bay✗ nodiscuss
…→Infusion pumps on the ward come from three manufacturers✗ nodiscuss
Pharmacy reviews charts a day after the first dose was given→…✗ nodiscuss
Weight-based doses are calculated by hand at the bedside→Interruptions during the drug round are constant✗ nodiscuss
Infusion pumps on the ward come from three manufacturers→Weight-based doses are calculated by hand at the bedside✗ nodiscuss
Night shift has one nurse for the whole bay→Pharmacy reviews charts a day after the first dose was given✗ nodiscuss
Reporting an error has led to disciplinary action in the past→Night shift has one nurse for the whole bay✗ nodiscuss
Pharmacy reviews charts a day after the first dose was given→Agency staff do not know the ward's conventions✗ nodiscuss
…→Agency staff do not know the ward's conventions✗ nodiscuss
Reporting an error has led to disciplinary action in the past→Infusion pumps on the ward come from three manufacturers✗ nodiscuss
Weight-based doses are calculated by hand at the bedside→Reporting an error has led to disciplinary action in the past✗ nodiscuss
Night shift has one nurse for the whole bay→Handwritten charts are still used when the system is down, which is often✗ nodiscuss
Infusion pumps on the ward come from three manufacturers→Reporting an error has led to disciplinary action in the past✗ nodiscuss
Weight-based doses are calculated by hand at the bedside→Pharmacy reviews charts a day after the first dose was given✗ nodiscuss
Pharmacy reviews charts a day after the first dose was given→Reporting an error has led to disciplinary action in the past✗ nodiscuss
…→Reporting an error has led to disciplinary action in the past✗ nodiscuss
Interruptions during the drug round are constant→Reporting an error has led to disciplinary action in the past✗ nodiscuss
Reporting an error has led to disciplinary action in the past→Interruptions during the drug round are constant✗ nodiscuss