2 similar incidents recorded in department 90-day window
Procedural safety observation (Surgical count discrepancy) in Biomedical Engineering
Occurred: 2025-03-11T23:49 UTC · Reported: 2025-03-16T13:49 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 23:49 UTC in Biomedical Engineering, a minor safety event occurred involving surgical count discrepancy. The incident was assigned preliminary risk score 28 in the Moderate band.
In Biomedical Engineering at 23:49, surgical team conducting safety checklist noted a variance relating to surgical count discrepancy. 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 Facilities
Semantic similarity calculated across category, location, and clinical narrative keywords.
Procedural safety observation (Surgical count discrepancy) in Biomedical Engineering
Procedural safety observation (Surgical count discrepancy) in Sterile Supply (CSSD)
Procedural safety observation (Surgical count discrepancy) in Sterile Supply (CSSD)
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)
Spoke with night NUM. Replacement harness fitted. Ward Sister confirms sensor mat returned to bed.
Spoke with night NUM. Replacement harness fitted. Ward Sister confirms sensor mat returned to bed.