Medication protocol variance (Wrong route) in Sterile Supply (CSSD)
Occurred: 2025-03-11T14:39 UTC · Reported: 2025-03-15T11:39 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 14:39 UTC in Sterile Supply (CSSD), a minor safety event occurred involving wrong route. The incident was assigned preliminary risk score 15 in the Low band.
At 14:39 in Sterile Supply (CSSD), staff observed a discrepancy regarding Warfarin administration involving wrong route. The second-check protocol identified the variance during preparation, preventing an incorrect dose reaching the patient.
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.
Medication protocol variance (Wrong route) in Sterile Supply (CSSD)
Medication protocol variance (Wrong route) in Sterile Supply (CSSD)
Medication protocol variance (Wrong route) 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 medication & iv fluids: standardized protocol enforcement and hardware interlock.
Parties Involved (2)
Masked by default per governance protocolHandover & Action Notes (2)
Pharmacy review completed. Order amended to weight-adjusted dosage; patient vitals stable at handover.
Pharmacy review completed. Order amended to weight-adjusted dosage; patient vitals stable at handover.