1 similar incident recorded in department 90-day window
Process discrepancy (Delayed escalation) in Sterile Supply (CSSD)
Occurred: 2025-03-05T00:24 UTC · Reported: 2025-03-09T11:24 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 00:24 UTC in Sterile Supply (CSSD), a moderate safety event occurred involving delayed escalation. The incident was assigned preliminary risk score 38 in the Moderate band.
During shift changeover in Sterile Supply (CSSD) at 00:24, staff flagged a variance regarding delayed escalation. Escalation was enacted according to protocol.
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.
Process discrepancy (Delayed escalation) in Sterile Supply (CSSD)
Process discrepancy (Delayed escalation) in Biomedical Engineering
Process discrepancy (Delayed escalation) in Biomedical Engineering
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 clinical process & handover: standardized protocol enforcement and hardware interlock.
Parties Involved (3)
Masked by default per governance protocolHandover & Action Notes (2)
Quarantine label placed on device #GH-800. Equipment pool supervisor requested replacement.
Quarantine label placed on device #GH-800. Equipment pool supervisor requested replacement.