Procedural safety observation (Pre-op checklist lapse) in Acute Care
Occurred: 2025-03-12T17:50 UTC · Reported: 2025-03-16T07:50 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 17:50 UTC in Acute Care, a near miss safety event occurred involving pre-op checklist lapse. The incident was assigned preliminary risk score 11 in the Low band.
In Acute Care at 17:50, surgical team conducting safety checklist noted a variance relating to pre-op checklist lapse. Formal pause was executed.
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 Emergency
Semantic similarity calculated across category, location, and clinical narrative keywords.
Procedural safety observation (Pre-op checklist lapse) in Acute Care
Procedural safety observation (Pre-op checklist lapse) in Acute Care
Procedural safety observation (Pre-op checklist lapse) in Acute Care
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 surgical & invasive procedures: standardized protocol enforcement and hardware interlock.
Parties Involved (2)
Masked by default per governance protocolHandover & Action Notes (2)
EHR order entry template updated to require explicit sliding-scale justification.
EHR order entry template updated to require explicit sliding-scale justification.