Process discrepancy (Patient identification check) in Sterile Compounding
Occurred: 2025-03-12T17:10 UTC · Reported: 2025-03-16T06:10 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 17:10 UTC in Sterile Compounding, a sentinel safety event occurred involving patient identification check. The incident was assigned preliminary risk score 78 in the Severe band.
During shift changeover in Sterile Compounding at 17:10, staff flagged a variance regarding patient identification check. Escalation was enacted according to protocol.
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 Pharmacy
Semantic similarity calculated across category, location, and clinical narrative keywords.
Process discrepancy (Patient identification check) in Sterile Compounding
Process discrepancy (Patient identification check) in Aseptic Unit
Process discrepancy (Patient identification check) in Aseptic Unit
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 process & handover: standardized protocol enforcement and hardware interlock.
Parties Involved (4)
Masked by default per governance protocolHandover & Action Notes (2)
Secondary nurse verification countersigned. Clinical lead verified no hemodynamic deterioration.
Secondary nurse verification countersigned. Clinical lead verified no hemodynamic deterioration.