Near misses are not reported because the form takes twenty minutes

a walkthrough with stand-ins — a demonstration, not a finding · root cause · sealed

It significantly influences

The same look-alike drugs are stored next to each other

certified · 14 yes · 1 no

What significantly influences it

Errors are discussed as individual mistakes, not as patterns

certified · 14 yes · 1 no

Judged not to be linked

The same error recurs on the same drug every few months

judged not to · 7 yes · 19 no · 3 abstained · cross-group

judged not to · 1 yes · 14 no

judged not to · 0 yes · 14 no · 1 abstained

judged not to · 1 yes · 13 no · 1 abstained

judged not to · 3 yes · 11 no · 1 abstained

judged not to · 2 yes · 13 no

judged not to · 6 yes · 20 no · 3 abstained · cross-group

judged not to · 1 yes · 14 no

judged not to · 2 yes · 11 no · 2 abstained

judged not to · 1 yes · 13 no · 1 abstained

judged not to · 2 yes · 11 no · 2 abstained

judged not to · 0 yes · 15 no

judged not to · 1 yes · 12 no · 2 abstained

judged not to · 1 yes · 12 no · 2 abstained

judged not to · 2 yes · 13 no

judged not to · 1 yes · 14 no

A group’s judgement, not a measurement. Demo room. On the atlas.

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Link: https://truecauses.org/c/3c4ac0e/2bf4e59-misses-reported-form-takes-minutes
As data: https://truecauses.org/c/3c4ac0e/2bf4e59.json

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