Equipment discrepancy (Tubing misconnection) in Sterile Supply (CSSD)
Occurred: 2025-03-05T15:30 UTC · Reported: 2025-03-10T07:30 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 15:30 UTC in Sterile Supply (CSSD), a none safety event occurred involving tubing misconnection. The incident was assigned preliminary risk score 6 in the Low band.
Staff in Sterile Supply (CSSD) identified that clinical equipment experienced tubing misconnection at 15:30. Clinical team verified patient safety and swapped device.
Risk Evaluation & Score Breakdown
Deterministic multi-term risk score from 1 to 100 derived from clinical harm, recurrence, and reporting lag.
Top Similar Incidents in Facilities
Semantic similarity calculated across category, location, and clinical narrative keywords.
Equipment discrepancy (Tubing misconnection) in Sterile Supply (CSSD)
Equipment discrepancy (Tubing misconnection) in Sterile Supply (CSSD)
Equipment discrepancy (Tubing misconnection) in Plant & Utilities
Root Cause Analysis & Safeguards Workspace
Explore 5 Whys causal pathways, 6-bone fishbone decomposition, and barrier analysis safeguards.
Corrective & Preventive Actions (1)
Implement systemic safeguard against medical equipment & devices: standardized protocol enforcement and hardware interlock.
Parties Involved (2)
Masked by default per governance protocolHandover & Action Notes (2)
Pharmacy review completed. Order amended to weight-adjusted dosage; patient vitals stable at handover.
Pharmacy review completed. Order amended to weight-adjusted dosage; patient vitals stable at handover.