SPØRGSMÅLET
Why do medication errors keep happening?
Brug dine klistermærker på det, der betyder mest. En idé med belæg kan få en reserveret plads.
lukket · tilbage til fasen Handlinger
Du ser med som gæst. Vælg et brugernavn for at komme med og deltage.
Dit budget af klistermærker
Én pr. idé, 5 i alt. Minimum er én stemme.
5 pladser er reserveret til oversete idéer — nominér én med et link, og den tæller, når 2 personer er enige om, at kilden er relevant.
hvorfor
Når fasen lukker, kommer én nomineret ind ved lodtrækning og resten efter antal nomineringer, højst én pr. interessentkategori. En model tjekker kun, om siden handler om samme emne — aldrig om den beviser påstanden. Den vurdering er rummets, og en nominering, som ingen andre bakker op, får ingen plads.
KLYNGE 1
Allergy information is in a different system from the prescribing one
stemmer: 3diskutér
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.
stemmer: 2diskutér
KLYNGE 2
Infusion pumps on the ward come from three manufacturers
stemmer: 5diskutér
The same look-alike drugs are stored next to each other
stemmer: 5diskutér
KLYNGE 3
Near misses are not reported because the form takes twenty minutes
stemmer: 7diskutér
Reporting an error has led to disciplinary action in the past
stemmer: 3diskutér
KLYNGE 4
Handwritten charts are still used when the system is down, which is often
stemmer: 9diskutér
The electronic chart times out and loses the entry
stemmer: 2diskutér
KLYNGE 5
Verbal orders are accepted over the phone without read-back
stemmer: 0diskutér
Double-checking is signed without a second person actually looking
Meaning the recurring pattern, not the one incident under review.
stemmer: 9
↳ nomineret til en plads: https://example.org/ops-incident-review.pdf could not read it (HTTPError) 1 af 2 bakker op
diskutérIKKE I EN KLYNGE
Pharmacy reviews charts a day after the first dose was given
stemmer: 3diskutér
The ward manager spends most of the shift covering gaps in the rota
stemmer: 2diskutér
Errors are discussed as individual mistakes, not as patterns
To be precise: this is about the system, not any nurse or doctor.
stemmer: 8diskutér
The same error recurs on the same drug every few months
Meaning the recurring pattern, not the one incident under review.
stemmer: 5diskutér
Nurses are measured on completing the round on time
stemmer: 2diskutér
Staffing is set by bed count, not by how sick the patients are
stemmer: 0diskutér
Patients are moved between wards mid-treatment and the chart lags behind
stemmer: 2diskutér
New nurses are put on drug rounds in their first week
stemmer: 2diskutér
The drug trolley is shared between two bays
stemmer: 0diskutér
Discharge medication lists disagree with the inpatient chart
stemmer: 13diskutér
Nobody looks at the error reports together
stemmer: 1diskutér
Night shift has one nurse for the whole bay
stemmer: 9diskutér
Prescriptions are written in the corridor between other tasks
stemmer: 1diskutér
Interruptions during the drug round are constant
stemmer: 9diskutér
Alerts in the system are so frequent that they are clicked through
Scope: this ward on this site, not the trust as a whole.
stemmer: 15diskutér
Weight-based doses are calculated by hand at the bedside
stemmer: 5diskutér
Doctors change doses verbally on the round and the chart is updated later
Meaning the recurring pattern, not the one incident under review.
stemmer: 0diskuteres (1)