1 similar incident recorded in department 90-day window
Documentation variance (Missing procedure consent) in NICU
Occurred: 2025-03-12T18:59 UTC · Reported: 2025-03-17T05:59 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 18:59 UTC in NICU, a severe safety event occurred involving missing procedure consent. The incident was assigned preliminary risk score 66 in the Severe band.
During procedural verification in NICU at 18:59, team identified that missing procedure consent was incomplete prior to commencement. Protocol was paused until validation was secured.
Risk Evaluation & Score Breakdown
Deterministic multi-term risk score from 1 to 100 derived from clinical harm, recurrence, and reporting lag.
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Documentation variance (Missing procedure consent) in NICU
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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 clinical documentation & consent: standardized protocol enforcement and hardware interlock.
Parties Involved (3)
Masked by default per governance protocolHandover & Action Notes (2)
Quarantine label placed on device #GH-800. Equipment pool supervisor requested replacement.
Quarantine label placed on device #GH-800. Equipment pool supervisor requested replacement.