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Metropolitan General Hospital · 420 beds

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DIRECT RECURRENCE OF PRIOR FAILURE MODE DETECTED
Pattern 5 Surfaced

2 similar incidents recorded in department 90-day window

Systemic safeguard did not prevent recurrence within 60 days
INC-2026-0015·Closed

Environmental safety hazard (Spill or wet floor slip) in Labour & Delivery

Occurred: 2025-03-07T19:26 UTC · Reported: 2025-03-12T02:26 UTC

20Moderate
DepartmentMaternity
Unit & RoomLabour & Delivery · Bay 8
Harm Levelnear miss
Patient ReferencePT-1015

Clinical Narrative & Synthesized Abstract

Synthesized Abstract: At 19:26 UTC in Labour & Delivery, a near miss safety event occurred involving spill or wet floor slip. The incident was assigned preliminary risk score 20 in the Moderate band.

At 19:26 in Labour & Delivery, staff observed spill or wet floor slip presenting potential slip or operational hazard. Area was isolated.

Strong signal(92%)|Because:
What this could not see: Informal verbal handover notes prior to admission are unrecorded

Risk Evaluation & Score Breakdown

Deterministic multi-term risk score from 1 to 100 derived from clinical harm, recurrence, and reporting lag.

Harm Base Score+5
Patients Affected+0
Recurrence in Window+12
Department Baseline-1
Detection Lag+4
External Reportability+0

Top Similar Incidents in Maternity

Semantic similarity calculated across category, location, and clinical narrative keywords.

3 matches
INC-2026-1695100% match

Environmental safety hazard (Spill or wet floor slip) in Labour & Delivery

Labour & Delivery2026-02-25
INC-2026-149585% match

Environmental safety hazard (Spill or wet floor slip) in Postnatal Ward

Postnatal Ward2026-01-14
INC-2026-015975% match

Environmental safety hazard (Water supply fluctuation) in Labour & Delivery

Labour & Delivery2025-04-07

Root Cause Analysis & Safeguards Workspace

Open Interactive RCA Workspace

Explore 5 Whys causal pathways, 6-bone fishbone decomposition, and barrier analysis safeguards.

Corrective & Preventive Actions (1)

CAPA-2026-0015engineering TierDue: 2026-09-17

Implement systemic safeguard against environmental safety: standardized protocol enforcement and hardware interlock.

draft

Parties Involved (3)

Masked by default per governance protocol
reporterreporter [Masked]
patientPatient 0040
involved staffStaff Member [0041]

Handover & Action Notes (2)

Quarantine label placed on device #GH-800. Equipment pool supervisor requested replacement.

Dr. Benjamin Cole (Executive)2025-03-12T02:26 UTC

Quarantine label placed on device #GH-800. Equipment pool supervisor requested replacement.

Clinician B. Rossi (Frontline staff)2025-03-12T02:26 UTC