Incorrect dosage administration of Morphine sulfate in Biomedical Engineering
Occurred: 2025-03-09T11:24 UTC · Reported: 2025-03-14T08:24 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 11:24 UTC in Biomedical Engineering, a near miss safety event occurred involving dosing error. The incident was assigned preliminary risk score 9 in the Low band.
During the morning medication round at 11:24, nursing staff identified that Morphine sulfate was prepared at a concentration exceeding prescribed chart dosage. Verification against the EMR chart revealed an order transcription variance. The infusion was suspended prior to complete administration.
Risk Evaluation & Score Breakdown
Deterministic multi-term risk score from 1 to 100 derived from clinical harm, recurrence, and reporting lag.
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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 (2)
Masked by default per governance protocolHandover & Action Notes (2)
Root cause debrief conducted with morning nursing team. Focus on verbal order readback adherence.
Root cause debrief conducted with morning nursing team. Focus on verbal order readback adherence.