SPØRGSMÅLET
Why do medication errors keep happening?
Saml sedler, du synes ligner hinanden. Klynger gør væggen lettere at læse; de afgør intet.
lukket · tilbage til fasen Handlinger
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Klynger dannes ud fra lighed, navnene kommer sidst
Fast rækkefølge: kobl par af idéer, du synes ligner hinanden — koblinger er symmetriske (A~B er B~A; retningen betyder aldrig noget), og en kobling holder, når 2 medlemmer har lavet den.
hvorfor
Koblinger er symmetriske — A~B er B~A. Klynger er de grupper, der opstår af koblinger, der holder, og kun en dannet klynge kan navngives, af et menneske. Dine egne koblinger har et ✕, så du kan trække dem tilbage; du kan ikke fjerne andres. Klynger ordner væggen og spærrer aldrig for afstemningen — to sedler, der fremsætter samme PÅSTAND, skal lægges sammen i fasen Præcisering.
Koblinger og navne laves, mens fasen Sortering er åben; tovholderens ← genåbner den.
unavngiven klynge — navngiv den, hvis sedlerne har en fælles tråd, eller lad den være unavngiven (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)
unavngiven klynge — navngiv den, hvis sedlerne har en fælles tråd, eller lad den være unavngiven (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)
unavngiven klynge — navngiv den, hvis sedlerne har en fælles tråd, eller lad den være unavngiven (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)
unavngiven klynge — navngiv den, hvis sedlerne har en fælles tråd, eller lad den være unavngiven (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)
unavngiven klynge — navngiv den, hvis sedlerne har en fælles tråd, eller lad den være unavngiven (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)
· endnu ikke i en klynge (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
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
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