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Why do medication errors keep happening?
Double-checking is signed without a second person actually looking
a walkthrough with stand-ins — a demonstration, not a finding · root cause · sealed
It significantly influences
Patients are moved between wards mid-treatment and the chart lags behind
certified · 14 yes · 0 no · 1 abstained
Discharge medication lists disagree with the inpatient chart
inferred · follows from certified links
Judged not to be linked
The same error recurs on the same drug every few months
judged not to · 3 yes · 12 no
Allergy information is in a different system from the prescribing one
judged not to · 1 yes · 14 no
The same look-alike drugs are stored next to each other
judged not to · 2 yes · 13 no
Near misses are not reported because the form takes twenty minutes
judged not to · 1 yes · 12 no · 2 abstained
New nurses are put on drug rounds in their first week
judged not to · 3 yes · 12 no
Errors are discussed as individual mistakes, not as patterns
judged not to · 3 yes · 12 no
Alerts in the system are so frequent that they are clicked through
judged not to · 1 yes · 14 no
The same error recurs on the same drug every few months
judged not to · 1 yes · 11 no · 3 abstained
Allergy information is in a different system from the prescribing one
judged not to · 1 yes · 14 no
The same look-alike drugs are stored next to each other
judged not to · 0 yes · 14 no · 1 abstained
Near misses are not reported because the form takes twenty minutes
judged not to · 2 yes · 13 no
New nurses are put on drug rounds in their first week
judged not to · 1 yes · 12 no · 2 abstained
Errors are discussed as individual mistakes, not as patterns
judged not to · 0 yes · 14 no · 1 abstained
Patients are moved between wards mid-treatment and the chart lags behind
judged not to · 2 yes · 12 no · 1 abstained
Discharge medication lists disagree with the inpatient chart
judged not to · 2 yes · 12 no · 1 abstained
Alerts in the system are so frequent that they are clicked through
judged not to · 2 yes · 11 no · 2 abstained
A group’s judgement, not a measurement. Demo room. On the atlas.
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Link: https://truecauses.org/c/3c4ac0e/88f10f0-double-checking-signed-person
As data: https://truecauses.org/c/3c4ac0e/88f10f0.json