Flow rate programming variance on Becton Dickinson Alaris Guardrails (Unit #S-412) in Resus
Occurred: 2025-03-08T06:41 UTC · Reported: 2025-03-12T09:41 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 06:41 UTC in Resus, a moderate safety event occurred involving pump rate programming. The incident was assigned preliminary risk score 45 in the High band.
At 06:41, primary nurse noted that an infusion on Becton Dickinson Alaris Guardrails (Unit #S-412) was running at 50 mL/hr instead of the chartered 25 mL/hr. The smart pump dose error reduction system limit was overridden during bed transfer. Total excess volume infused was approximately 35 mL.
Risk Evaluation & Score Breakdown
Deterministic multi-term risk score from 1 to 100 derived from clinical harm, recurrence, and reporting lag.
Score overridden from 45 to 33 by Dr. Helena Chen on 2025-03-12.
"Clinical assessment downgraded: immediate mitigating intervention prevented systemic patient exposure."
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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 medication & iv fluids: standardized protocol enforcement and hardware interlock.
Parties Involved (3)
Masked by default per governance protocolHandover & Action Notes (2)
Discussed case at weekly multi-disciplinary quality committee; escalated to departmental risk register.
Discussed case at weekly multi-disciplinary quality committee; escalated to departmental risk register.