True Causes
VI
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Why do medication errors keep happening?
Agency staff do not know the ward's conventions
a walkthrough with stand-ins — a demonstration, not a finding · sealed
What significantly influences it
Infusion pumps on the ward come from three manufacturers
certified · 13 yes · 1 no
Judged not to be linked
Handwritten charts are still used when the system is down, which is often
judged not to · 1 yes · 13 no
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 · 12 no
Allergy information is in a different system from the prescribing one
judged not to · 2 yes · 11 no · 1 abstained
Night shift has one nurse for the whole bay
judged not to · 1 yes · 12 no · 1 abstained
Reporting an error has led to disciplinary action in the past
judged not to · 3 yes · 11 no
Infusion pumps on the ward come from three manufacturers
judged not to · 3 yes · 10 no · 1 abstained
Handwritten charts are still used when the system is down, which is often
judged not to · 2 yes · 11 no · 1 abstained
Pharmacy reviews charts a day after the first dose was given
judged not to · 1 yes · 13 no
Weight-based doses are calculated by hand at the bedside
judged not to · 2 yes · 11 no · 1 abstained
Interruptions during the drug round are constant
judged not to · 3 yes · 10 no · 1 abstained
Allergy information is in a different system from the prescribing one
judged not to · 2 yes · 11 no · 1 abstained
Night shift has one nurse for the whole bay
judged not to · 0 yes · 12 no · 2 abstained
Reporting an error has led to disciplinary action in the past
judged not to · 6 yes · 21 no · 2 abstained · cross-group
A group’s judgement, not a measurement. Demo room. On the atlas.
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Link: https://truecauses.org/c/3c4ac0e/ecba340-agency-staff-ward-conventions
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