问题
Why do medication errors keep happening?
把你认为相似的卡片归为一类。分类只为方便阅读，不决定任何事。
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先按相似性形成类别，最后再命名
标准顺序：把你认为相似的想法两两关联——关联是对称的（A~B 即 B~A；方向无关紧要），一条关联在 2 名成员做出后成立。
为什么
关联是对称的——A~B 即 B~A。类别是从成立的关联中自然形成的分组，只有已形成的类别才能被人命名。你自己的关联带有 ✕，可以撤回；你不能移除别人的。类别只用于整理墙，从不限制投票——两张提出相同主张的卡片属于澄清阶段的合并。
关联和命名只能在归类阶段进行；主持人的 ← 可以重新开启它。
未命名类别 ——如果这一类有共同主线就为它命名，否则保持未命名 (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)
未命名类别 ——如果这一类有共同主线就为它命名，否则保持未命名 (2)
Verbal orders are accepted over the phone without read-back
~ Double-checking is si…Double-checking is signed without a second person actually looking (16)
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)
未命名类别 ——如果这一类有共同主线就为它命名，否则保持未命名 (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)
未命名类别 ——如果这一类有共同主线就为它命名，否则保持未命名 (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)
未命名类别 ——如果这一类有共同主线就为它命名，否则保持未命名 (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)
· 尚未归类 (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
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