True
Causes
СР
Bahasa Indonesia
Dansk
Deutsch
English
Español
Français
Italiano
Nederlands
Norsk
Polski
Português
Srpski (latinica)
Svenska
Tiếng Việt
Türkçe
Ελληνικά
Русский
Српски (ћирилица)
Українська
中文
日本語
한국어
Why do medication errors keep happening?
Handwritten charts are still used when the system is down, which is often
a walkthrough with stand-ins — a demonstration, not a finding · root cause · sealed
It significantly influences
Infusion pumps on the ward come from three manufacturers
certified ·
14 yes · 0 no
Judged not to be linked
Pharmacy reviews charts a day after the first dose was given
judged not to ·
0 yes · 14 no
Weight-based doses are calculated by hand at the bedside
judged not to ·
2 yes · 12 no
Verbal orders are accepted over the phone without read-back
judged not to ·
2 yes · 11 no · 1 abstained
Interruptions during the drug round are constant
judged not to ·
2 yes · 11 no · 1 abstained
Allergy information is in a different system from the prescribing one
judged not to ·
1 yes · 13 no
Night shift has one nurse for the whole bay
judged not to ·
2 yes · 12 no
Reporting an error has led to disciplinary action in the past
judged not to ·
3 yes · 11 no
Agency staff do not know the ward's conventions
judged not to ·
2 yes · 11 no · 1 abstained
Pharmacy reviews charts a day after the first dose was given
judged not to ·
0 yes · 12 no · 2 abstained
Weight-based doses are calculated by hand at the bedside
judged not to ·
2 yes · 12 no
Verbal orders are accepted over the phone without read-back
judged not to ·
1 yes · 12 no · 1 abstained
Interruptions during the drug round are constant
judged not to ·
1 yes · 13 no
Allergy information is in a different system from the prescribing one
judged not to ·
2 yes · 10 no · 2 abstained
Night shift has one nurse for the whole bay
judged not to ·
2 yes · 12 no
Reporting an error has led to disciplinary action in the past
judged not to ·
1 yes · 12 no · 1 abstained
Agency staff do not know the ward's conventions
judged not to ·
1 yes · 13 no
Infusion pumps on the ward come from three manufacturers
judged not to ·
1 yes · 13 no
A group’s judgement, not a measurement. Demo room.
On the atlas
.
↗ cite or embed this claim
Link:
https://truecauses.org/c/3c4ac0e/35cf04a-handwritten-charts
As data:
https://truecauses.org/c/3c4ac0e/35cf04a.json
<iframe src="https://truecauses.org/embed/3c4ac0e/35cf04a" width="100%" height="360" style="border:0" loading="lazy"></iframe>