Infection protocol variance (PPE degradation) in Haematology
Occurred: 2025-03-07T08:48 UTC · Reported: 2025-03-11T12:48 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 08:48 UTC in Haematology, a minor safety event occurred involving ppe degradation. The incident was assigned preliminary risk score 14 in the Low band.
Routine surveillance check in Haematology at 08:48 noted an issue involving ppe degradation. The duty sister intercepted the procedure and rectified aseptic protocol.
Risk Evaluation & Score Breakdown
Deterministic multi-term risk score from 1 to 100 derived from clinical harm, recurrence, and reporting lag.
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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 infection prevention & control: 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.