Process discrepancy (Specimen mislabeling) in Labour & Delivery
Occurred: 2025-03-09T04:48 UTC · Reported: 2025-03-13T14:48 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 04:48 UTC in Labour & Delivery, a none safety event occurred involving specimen mislabeling. The incident was assigned preliminary risk score 5 in the Low band.
During shift changeover in Labour & Delivery at 04:48, staff flagged a variance regarding specimen mislabeling. 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 Maternity
Semantic similarity calculated across category, location, and clinical narrative keywords.
Process discrepancy (Specimen mislabeling) in Postnatal Ward
Process discrepancy (Delayed escalation) in Labour & Delivery
Process discrepancy (Shift handover omission) in Labour & Delivery
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 (2)
Masked by default per governance protocolHandover & Action Notes (2)
Biomedical service checked unit. Error code reset after capacitor swap; recalibration certificate issued.
Biomedical service checked unit. Error code reset after capacitor swap; recalibration certificate issued.