Slip during commode transfer in Pod A
Occurred: 2025-03-11T00:42 UTC · Reported: 2025-03-14T16:42 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 00:42 UTC in Pod A, a near miss safety event occurred involving bedside transfer. The incident was assigned preliminary risk score 8 in the Low band.
During assisted transfer from bed to bedside commode at 00:42, patient experienced sudden knee buckling. Two healthcare assistants assisted patient safely to the floor without direct impact or injury.
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 ICU
Semantic similarity calculated across category, location, and clinical narrative keywords.
Slip during commode transfer in Pod A
Slip during commode transfer in Pod A
Slip during commode transfer in Pod A
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 patient falls: standardized protocol enforcement and hardware interlock.
Parties Involved (3)
Masked by default per governance protocolHandover & Action Notes (2)
Attending physician notified. Urgent plain film radiography reviewed; no cortical breach identified.
Attending physician notified. Urgent plain film radiography reviewed; no cortical breach identified.