1 similar incident recorded in department 90-day window
Infection protocol variance (Central line protocol lapse) in Resus
Occurred: 2025-03-09T19:28 UTC · Reported: 2025-03-13T10:28 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 19:28 UTC in Resus, a near miss safety event occurred involving central line protocol lapse. The incident was assigned preliminary risk score 17 in the Low band.
Routine surveillance check in Resus at 19:28 noted an issue involving central line protocol lapse. 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.
Top Similar Incidents in Emergency
Semantic similarity calculated across category, location, and clinical narrative keywords.
Infection protocol variance (Central line protocol lapse) in Resus
Infection protocol variance (Central line protocol lapse) in Resus
Infection protocol variance (Central line protocol lapse) in Resus
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)
Spoke with night NUM. Replacement harness fitted. Ward Sister confirms sensor mat returned to bed.
Spoke with night NUM. Replacement harness fitted. Ward Sister confirms sensor mat returned to bed.