PASOŠ · ŠTA JE OVA SOBA URADILA
Why do medication errors keep happening?
Svaki red je iz zapisa. Ništa se ne izračunava za ovu stranicu i ništa se ne ulepšava: kratak spisak neslaganja znači sobu koja se složila, a ne sobu čija su neslaganja sklonjena.
| strukturira | prepreke |
| otvorena | 08 Sep 2026 |
| ko je odgovarao | ljudi: 30, grupa: 2 · učesnik: 30 |
| pisali naslepo | nije zabeleženo |
| tvrdnje | napisano: 28, strukturirano: 20 |
| potvrđene veze | 12 |
| sobe o ovom pitanju | 1 · ne računa se u zajedničkoj mapi |
| prag odluke | 75% datih glasova |
| zapečaćeno | da, članovi su zaboravljeni |
Na čemu počiva- Errors are discussed as individual mistakes, not as patterns
- Double-checking is signed without a second person actually looking
- Handwritten charts are still used when the system is down, which is often
- Pharmacy reviews charts a day after the first dose was given
- Allergy information is in a different system from the prescribing one
- Near misses are not reported because the form takes twenty minutes
Šta soba nije mogla da rešiObjavljeno kao sporno, nikad zabeleženo kao „ne”.
- nema: svaki par do kog je soba stigla je rešen
Šta je predviđeno da uslediNapisano pošto je mapa rešena. Niko nije glasao o tome.
- Staff nights by acuity score, not by bed count — očekuje se: fewer errors once the drug round cannot be interrupted — rok: 24 Mar 2027
Šta bi soba uradilaSvaka akcija ocenjena prema svakom osnovnom uzroku, sa tri četvrtine datih glasova.
- Staff nights by acuity score, not by bed count
podeljeno: Pharmacy reviews charts a day after the first dose was given - A near-miss report that takes two minutes and never names a person
podeljeno: Handwritten charts are still used when the system is down, which is often - Protected drug rounds: a tabard and a rule that only a patient emergency interrupts
smanjuje: Handwritten charts are still used when the system is down, which is often
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