True Causes
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Why do medication errors keep happening?
Alerts in the system are so frequent that they are clicked through
a walkthrough with stand-ins — a demonstration, not a finding · sealed
What significantly influences it
Allergy information is in a different system from the prescribing one
certified · 13 yes · 2 no
Judged not to be linked
The same error recurs on the same drug every few months
judged not to · 2 yes · 11 no · 2 abstained
Allergy information is in a different system from the prescribing one
judged not to · 3 yes · 11 no · 1 abstained
The same look-alike drugs are stored next to each other
judged not to · 0 yes · 15 no
Near misses are not reported because the form takes twenty minutes
judged not to · 1 yes · 14 no
New nurses are put on drug rounds in their first week
judged not to · 2 yes · 13 no
Errors are discussed as individual mistakes, not as patterns
judged not to · 5 yes · 24 no · cross-group
Patients are moved between wards mid-treatment and the chart lags behind
judged not to · 2 yes · 12 no · 1 abstained
Double-checking is signed without a second person actually looking
judged not to · 2 yes · 11 no · 2 abstained
Discharge medication lists disagree with the inpatient chart
judged not to · 1 yes · 14 no
The same error recurs on the same drug every few months
judged not to · 1 yes · 14 no
The same look-alike drugs are stored next to each other
judged not to · 1 yes · 13 no · 1 abstained
Near misses are not reported because the form takes twenty minutes
judged not to · 1 yes · 14 no
New nurses are put on drug rounds in their first week
judged not to · 2 yes · 12 no · 1 abstained
Errors are discussed as individual mistakes, not as patterns
judged not to · 2 yes · 10 no · 3 abstained
Patients are moved between wards mid-treatment and the chart lags behind
judged not to · 3 yes · 12 no
Double-checking is signed without a second person actually looking
judged not to · 1 yes · 14 no
Discharge medication lists disagree with the inpatient chart
judged not to · 0 yes · 14 no · 1 abstained
A group’s judgement, not a measurement. Demo room. On the atlas.
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Link: https://truecauses.org/c/3c4ac0e/e36cccd-alerts-frequent-clicked
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