Documentation variance (Unsigned protocol) in Sterile Supply (CSSD)
Occurred: 2025-03-07T11:53 UTC · Reported: 2025-03-10T21:53 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 11:53 UTC in Sterile Supply (CSSD), a none safety event occurred involving unsigned protocol. The incident was assigned preliminary risk score 5 in the Low band.
During procedural verification in Sterile Supply (CSSD) at 11:53, team identified that unsigned protocol was incomplete prior to commencement. Protocol was paused until validation was secured.
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.
Documentation variance (Unsigned protocol) in Sterile Supply (CSSD)
Documentation variance (Unsigned protocol) in Biomedical Engineering
Documentation variance (Unsigned protocol) 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 documentation & consent: standardized protocol enforcement and hardware interlock.
Parties Involved (3)
Masked by default per governance protocolHandover & Action Notes (2)
Biomedical service checked unit. Error code reset after capacitor swap; recalibration certificate issued.
Biomedical service checked unit. Error code reset after capacitor swap; recalibration certificate issued.