True Causes
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Why do medication errors keep happening?
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30 people · 28 ideas · 2 groups
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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Questions are shared out between groups, so you get the ones your group was given — not all 180.
why
Nobody could answer several hundred pairs. Each pair goes to one group; a pair that splits is then referred to other groups, so it can appear in your list later even though it started elsewhere. The settled count includes every group's work, which is why it climbs faster than your own list shrinks.
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.
close ✕
Discharge medication lists disagree with the inpatient chart → influences? → Double-checking is signed without a second person actually looking
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✗ noin focus ↑ · close ✕
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✗ nodiscuss
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