Process discrepancy (Critical lab value delayed) in Biochemistry
Occurred: 2025-03-07T10:35 UTC · Reported: 2025-03-10T22:35 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 10:35 UTC in Biochemistry, a minor safety event occurred involving critical lab value delayed. The incident was assigned preliminary risk score 13 in the Low band.
During shift changeover in Biochemistry at 10:35, staff flagged a variance regarding critical lab value delayed. 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 Pathology
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Process discrepancy (Critical lab value delayed) in Biochemistry
Process discrepancy (Critical lab value delayed) in Biochemistry
Delayed triage: Critical serum potassium result reporting delay from Pathology
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 (4)
Masked by default per governance protocolHandover & Action Notes (2)
Attending physician notified. Urgent plain film radiography reviewed; no cortical breach identified.
Attending physician notified. Urgent plain film radiography reviewed; no cortical breach identified.