Medication protocol variance (Wrong route) in NICU
Occurred: 2025-03-06T16:03 UTC · Reported: 2025-03-10T13:03 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 16:03 UTC in NICU, a near miss safety event occurred involving wrong route. The incident was assigned preliminary risk score 7 in the Low band.
At 16:03 in NICU, staff observed a discrepancy regarding Morphine sulfate administration involving wrong route. The second-check protocol identified the variance during preparation, preventing an incorrect dose reaching the patient.
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 Maternity
Semantic similarity calculated across category, location, and clinical narrative keywords.
Medication protocol variance (Wrong route) in NICU
Medication protocol variance (Wrong route) in NICU
Medication protocol variance (Wrong route) in NICU
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 medication & iv fluids: standardized protocol enforcement and hardware interlock.
Parties Involved (2)
Masked by default per governance protocolHandover & Action Notes (2)
EHR order entry template updated to require explicit sliding-scale justification.
EHR order entry template updated to require explicit sliding-scale justification.