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INC-2026-0031·Closed

Environmental safety hazard (Emergency exit obstructed) in Ambulatory

Occurred: 2025-03-11T10:02 UTC · Reported: 2025-03-14T19:02 UTC

11Low
DepartmentEmergency
Unit & RoomAmbulatory · Bay 8
Harm Levelnear miss
Patient ReferencePT-1031

Clinical Narrative & Synthesized Abstract

Synthesized Abstract: At 10:02 UTC in Ambulatory, a near miss safety event occurred involving emergency exit obstructed. The incident was assigned preliminary risk score 11 in the Low band.

At 10:02 in Ambulatory, staff observed emergency exit obstructed presenting potential slip or operational hazard. Area was isolated.

Strong signal(92%)|Because:
What this could not see: Informal verbal handover notes prior to admission are unrecorded

Risk Evaluation & Score Breakdown

Deterministic multi-term risk score from 1 to 100 derived from clinical harm, recurrence, and reporting lag.

Harm Base Score+5
Patients Affected+0
Recurrence in Window+0
Department Baseline+3
Detection Lag+3
External Reportability+0
Human Clinical Override Active

Score overridden from 11 to 1 by Dr. Marcus Sterling on 2025-03-14.

"Clinical assessment downgraded: immediate mitigating intervention prevented systemic patient exposure."

Top Similar Incidents in Emergency

Semantic similarity calculated across category, location, and clinical narrative keywords.

3 matches
INC-2026-0071100% match

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INC-2026-0151100% match

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INC-2026-0191100% match

Environmental safety hazard (Emergency exit obstructed) in Ambulatory

Ambulatory2025-04-14

Root Cause Analysis & Safeguards Workspace

Open Interactive RCA Workspace

Explore 5 Whys causal pathways, 6-bone fishbone decomposition, and barrier analysis safeguards.

Corrective & Preventive Actions (1)

CAPA-2026-0031training TierDue: 2026-09-17

Implement systemic safeguard against environmental safety: standardized protocol enforcement and hardware interlock.

draft

Parties Involved (4)

Masked by default per governance protocol
reporterreporter [Masked]
patientPatient 0083
involved staffStaff Member [0084]
witnesswitness [Masked]

Handover & Action Notes (2)

Biomedical service checked unit. Error code reset after capacitor swap; recalibration certificate issued.

Nurse Maria Santos (Frontline staff)2025-03-14T19:02 UTC

Biomedical service checked unit. Error code reset after capacitor swap; recalibration certificate issued.

Dr. Rebecca Ross (Department Head)2025-03-14T19:02 UTC