Documentation variance (Delayed discharge summary) in Ambulatory
Occurred: 2025-03-10T18:20 UTC · Reported: 2025-03-14T09:20 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 18:20 UTC in Ambulatory, a none safety event occurred involving delayed discharge summary. The incident was assigned preliminary risk score 8 in the Low band.
During procedural verification in Ambulatory at 18:20, team identified that delayed discharge summary was incomplete prior to commencement. Protocol was paused until validation was secured.
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.
Documentation variance (Delayed discharge summary) in Ambulatory
Documentation variance (Delayed discharge summary) in Ambulatory
Documentation variance (Delayed discharge summary) in Ambulatory
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 documentation & consent: standardized protocol enforcement and hardware interlock.
Parties Involved (3)
Masked by default per governance protocolHandover & Action Notes (2)
Secondary nurse verification countersigned. Clinical lead verified no hemodynamic deterioration.
Secondary nurse verification countersigned. Clinical lead verified no hemodynamic deterioration.