THE QUESTION
Why do medication errors keep happening?
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merged "Nobody files a near-miss repor…" → "Near misses are not reported b…"
Pharmacy reviews charts a day after the first dose was given
The ward manager spends most of the shift covering gaps in the rota
Handwritten charts are still used when the system is down, which is often
cluster 4discuss
Errors are discussed as individual mistakes, not as patterns
To be precise: this is about the system, not any nurse or doctor.
Verbal orders are accepted over the phone without read-back
cluster 5discuss
The same error recurs on the same drug every few months
Meaning the recurring pattern, not the one incident under review.
The electronic chart times out and loses the entry
cluster 4discuss
Nurses are measured on completing the round on time
Staffing is set by bed count, not by how sick the patients are
Infusion pumps on the ward come from three manufacturers
cluster 2discuss
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
The drug trolley is shared between two bays
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
The same look-alike drugs are stored next to each other
cluster 2discuss
Allergy information is in a different system from the prescribing one
cluster 1discuss
Double-checking is signed without a second person actually looking
Meaning the recurring pattern, not the one incident under review.
cluster 5discuss
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.
cluster 1discuss
Near misses are not reported because the form takes twenty minutes
cluster 3discuss
Interruptions during the drug round are constant
Alerts in the system are so frequent that they are clicked through
Scope: this ward on this site, not the trust as a whole.
Weight-based doses are calculated by hand at the bedside
Reporting an error has led to disciplinary action in the past
cluster 3discuss
Doctors change doses verbally on the round and the chart is updated later
Meaning the recurring pattern, not the one incident under review.