Procedural safety observation (Specimen labeling in theatre) in Sterile Compounding
Occurred: 2025-03-09T18:25 UTC · Reported: 2025-03-13T10:25 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 18:25 UTC in Sterile Compounding, a none safety event occurred involving specimen labeling in theatre. The incident was assigned preliminary risk score 6 in the Low band.
In Sterile Compounding at 18:25, surgical team conducting safety checklist noted a variance relating to specimen labeling in theatre. Formal pause was executed.
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 Pharmacy
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Procedural safety observation (Specimen labeling in theatre) in Sterile Compounding
Procedural safety observation (Specimen labeling in theatre) in Aseptic Unit
Procedural safety observation (Specimen labeling in theatre) in Aseptic Unit
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 surgical & invasive procedures: standardized protocol enforcement and hardware interlock.
Parties Involved (2)
Masked by default per governance protocolHandover & Action Notes (2)
Pharmacy review completed. Order amended to weight-adjusted dosage; patient vitals stable at handover.
Pharmacy review completed. Order amended to weight-adjusted dosage; patient vitals stable at handover.