Why do medication errors keep happening?
a walkthrough with stand-ins — a demonstration, not a finding · 12 certified links · outlined boxes are the roots · tap a claim to read it in full
Showing every action the room judged: it acts directly on 1 of the 6 root causes. It does not act directly on 5.
Allergy information is in a different system from the prescribing one → The same look-alike drugs are stored next to each otherAllergy information is in a different system from the prescribing one → Alerts in the system are so frequent that they are clicked throughNear misses are not reported because the form takes twenty minutes → The same look-alike drugs are stored next to each otherHandwritten charts are still used when the system is down, which is often → Infusion pumps on the ward come from three manufacturersPharmacy reviews charts a day after the first dose was given → Night shift has one nurse for the whole bayErrors are discussed as individual mistakes, not as patterns → The same error recurs on the same drug every few monthsErrors are discussed as individual mistakes, not as patterns → Near misses are not reported because the form takes twenty minutesPatients are moved between wards mid-treatment and the chart lags behind → Discharge medication lists disagree with the inpatient chartDouble-checking is signed without a second person actually looking → Patients are moved between wards mid-treatment and the chart lags behindNight shift has one nurse for the whole bay → Interruptions during the drug round are constantInfusion pumps on the ward come from three manufacturers → Agency staff do not know the ward's conventionsAllergy information is in a different system from the prescribing oneAllergy information is in adifferent system from theprescribing onewhat the shown actions do to this root causeNO ACTION ACTS ON ITDIRECTLYHandwritten charts are still used when the system is down, which is oftenHandwritten charts arestill used when the systemis down, which is often③what the shown actions do to this root causeREDUCED BY 1 ACTIONPharmacy reviews charts a day after the first dose was givenPharmacy reviews charts aday after the first dosewas givenwhat the shown actions do to this root causeNO ACTION ACTS ON ITDIRECTLYErrors are discussed as individual mistakes, not as patternsErrors are discussed asindividual mistakes, not aspatternswhat the shown actions do to this root causeNO ACTION ACTS ON ITDIRECTLYDouble-checking is signed without a second person actually lookingDouble-checking is signedwithout a second personactually lookingwhat the shown actions do to this root causeNO ACTION ACTS ON ITDIRECTLYPatients are moved between wards mid-treatment and the chart lags behindPatients are moved betweenwards mid-treatment and thechart lags behindNear misses are not reported because the form takes twenty minutesNear misses are notreported because the formtakes twenty minuteswhat the shown actions do to this root causeNO ACTION ACTS ON ITDIRECTLYThe same error recurs on the same drug every few monthsThe same error recurs onthe same drug every fewmonthsNight shift has one nurse for the whole bayNight shift has one nursefor the whole bayInfusion pumps on the ward come from three manufacturersInfusion pumps on the wardcome from threemanufacturersAlerts in the system are so frequent that they are clicked throughAlerts in the system are sofrequent that they areclicked throughDischarge medication lists disagree with the inpatient chartDischarge medication listsdisagree with the inpatientchartThe same look-alike drugs are stored next to each otherThe same look-alike drugsare stored next to eachotherInterruptions during the drug round are constantInterruptions during thedrug round are constantAgency staff do not know the ward's conventionsAgency staff do not knowthe ward's conventions
WHAT WAS PREDICTED TO FOLLOW
Each number on the map marks a root cause that action reduces.
① Staff nights by acuity score, not by bed count
we expect: fewer errors once the drug round cannot be interrupted
measured by: medication errors reported per 1,000 doses
due 24 Mar 2027
guesses: the room: 3 (median of 15, spread 1.8 to 4.8)
② A near-miss report that takes two minutes and never names a person
no prediction about this action yet
③ Protected drug rounds: a tabard and a rule that only a patient emergency interrupts
no prediction about this action yet
A map from True Causes: a group’s judgement, not a measurement.