True Causes
ID
Bahasa IndonesiaDanskDeutschEnglishEspañolFrançaisItalianoNederlandsNorskPolskiPortuguêsSrpski (latinica)SvenskaTiếng ViệtTürkçeΕλληνικάРусскийСрпски (ћирилица)Українська中文日本語한국어
Why do medication errors keep happening?
Errors are discussed as individual mistakes, not as patterns
a walkthrough with stand-ins — a demonstration, not a finding · root cause · sealed
It significantly influences
The same error recurs on the same drug every few months
certified · 12 yes · 3 no
Near misses are not reported because the form takes twenty minutes
certified · 14 yes · 1 no
Judged not to be linked
Allergy information is in a different system from the prescribing one
judged not to · 0 yes · 13 no · 2 abstained
The same look-alike drugs are stored next to each other
judged not to · 1 yes · 11 no · 3 abstained
New nurses are put on drug rounds in their first week
judged not to · 8 yes · 21 no · cross-group
Patients are moved between wards mid-treatment and the chart lags behind
judged not to · 7 yes · 22 no · cross-group
Double-checking is signed without a second person actually looking
judged not to · 0 yes · 14 no · 1 abstained
Discharge medication lists disagree with the inpatient chart
judged not to · 3 yes · 11 no · 1 abstained
Alerts in the system are so frequent that they are clicked through
judged not to · 2 yes · 10 no · 3 abstained
The same error recurs on the same drug every few months
judged not to · 0 yes · 14 no · 1 abstained
Allergy information is in a different system from the prescribing one
judged not to · 0 yes · 15 no
The same look-alike drugs are stored next to each other
judged not to · 4 yes · 24 no · 1 abstained · cross-group
Near misses are not reported because the form takes twenty minutes
judged not to · 1 yes · 13 no · 1 abstained
New nurses are put on drug rounds in their first week
judged not to · 1 yes · 12 no · 2 abstained
Double-checking is signed without a second person actually looking
judged not to · 3 yes · 12 no
Discharge medication lists disagree with the inpatient chart
judged not to · 3 yes · 11 no · 1 abstained
Alerts in the system are so frequent that they are clicked through
judged not to · 5 yes · 24 no · cross-group
A group’s judgement, not a measurement. Demo room. On the atlas.
↗ cite or embed this claim
Link: https://truecauses.org/c/3c4ac0e/626fd23-errors-discussed-individual-mistakes
As data: https://truecauses.org/c/3c4ac0e/626fd23.json