1 similar incident recorded in department 90-day window
Flow rate programming variance on Becton Dickinson Alaris Guardrails (Unit #S-412) in Ward 2A
Occurred: 2025-03-13T16:08 UTC · Reported: 2025-03-17T21:08 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 16:08 UTC in Ward 2A, a near miss safety event occurred involving pump rate programming. The incident was assigned preliminary risk score 15 in the Low band.
At 16:08, primary nurse noted that an infusion on Becton Dickinson Alaris Guardrails (Unit #S-412) was running at 50 mL/hr instead of the chartered 25 mL/hr. The smart pump dose error reduction system limit was overridden during bed transfer. Total excess volume infused was approximately 35 mL.
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 Surgical
Semantic similarity calculated across category, location, and clinical narrative keywords.
Flow rate programming variance on Fresenius Kabi Agilia (Unit #I-303) in Ward 2A
Flow rate programming variance on Becton Dickinson Alaris Guardrails (Unit #S-412) in Ward 2A
Flow rate programming variance on Braun Space Infusomat (Unit #M-109) in Ward 2A
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 medication & iv fluids: standardized protocol enforcement and hardware interlock.
Parties Involved (3)
Masked by default per governance protocolHandover & Action Notes (2)
Spoke with night NUM. Replacement harness fitted. Ward Sister confirms sensor mat returned to bed.
Spoke with night NUM. Replacement harness fitted. Ward Sister confirms sensor mat returned to bed.