Process discrepancy (Shift handover omission) in Triage
Occurred: 2025-03-10T01:59 UTC · Reported: 2025-03-14T01:59 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 01:59 UTC in Triage, a near miss safety event occurred involving shift handover omission. The incident was assigned preliminary risk score 12 in the Low band.
During shift changeover in Triage at 01:59, staff flagged a variance regarding shift handover omission. 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 Emergency
Semantic similarity calculated across category, location, and clinical narrative keywords.
Process discrepancy (Shift handover omission) in Triage
Process discrepancy (Shift handover omission) in Triage
Process discrepancy (Shift handover omission) in Triage
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 (3)
Masked by default per governance protocolHandover & Action Notes (2)
Patient and family briefed by consultant regarding sequence of events; open disclosure logged.
Patient and family briefed by consultant regarding sequence of events; open disclosure logged.