Equipment discrepancy (Alarm volume muted) in Postnatal Ward
Occurred: 2025-03-11T05:20 UTC · Reported: 2025-03-15T14:20 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 05:20 UTC in Postnatal Ward, a none safety event occurred involving alarm volume muted. The incident was assigned preliminary risk score 5 in the Low band.
Staff in Postnatal Ward identified that clinical equipment experienced alarm volume muted at 05:20. Clinical team verified patient safety and swapped device.
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 Maternity
Semantic similarity calculated across category, location, and clinical narrative keywords.
Equipment discrepancy (Alarm volume muted) in Postnatal Ward
Equipment discrepancy (Alarm volume muted) in Postnatal Ward
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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 medical equipment & devices: standardized protocol enforcement and hardware interlock.
Parties Involved (2)
Masked by default per governance protocolHandover & Action Notes (2)
Root cause debrief conducted with morning nursing team. Focus on verbal order readback adherence.
Root cause debrief conducted with morning nursing team. Focus on verbal order readback adherence.