PITANJE
Why do medication errors keep happening?
Grupišite kartice koje smatrate sličnim. Klasteri olakšavaju čitanje; ništa ne odlučuju.
zatvoreno · nazad na fazu Akcije
Gledate kao gost. Unesite korisničko ime da biste se pridružili i učestvovali.
Klasteri nastaju iz sličnosti, imena dolaze na kraju
Ustaljen redosled: povežite parove ideja koje smatrate sličnim — veze su simetrične (A~B je isto što i B~A; smer nikad nije važan), a veza važi kada je napravi dovoljno članova (2).
zašto
Veze su simetrične — A~B je isto što i B~A. Klasteri su skupovi koji nastaju iz veza koje važe, i samo nastali klaster može da dobije ime, i to od osobe. Uz vaše veze stoji ✕ za povlačenje; tuđe veze ne možete da uklonite. Klasteri uređuju zid i nikad ne ograničavaju glasanje — dve kartice koje iznose istu TVRDNJU spajaju se, i to u fazi Pojašnjavanje.
Veze i imena se prave dok je faza Grupisanje otvorena; voditeljevo ← je ponovo otvara.
Doctors change doses verbally on the round and the chart is updated later
Meaning the recurring pattern, not the one incident under review.
Which of these does the trust actually measure?
klaster bez imena — dajte mu ime ako grupa u njemu vidi zajedničku nit, ili ga ostavite bez imena (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)
klaster bez imena — dajte mu ime ako grupa u njemu vidi zajedničku nit, ili ga ostavite bez imena (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)
klaster bez imena — dajte mu ime ako grupa u njemu vidi zajedničku nit, ili ga ostavite bez imena (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)
klaster bez imena — dajte mu ime ako grupa u njemu vidi zajedničku nit, ili ga ostavite bez imena (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)
klaster bez imena — dajte mu ime ako grupa u njemu vidi zajedničku nit, ili ga ostavite bez imena (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)
· još nije u klasteru (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
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