Documentation variance (Verbal order handover) in Recovery
Occurred: 2025-03-13T14:37 UTC · Reported: 2025-03-18T06:37 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 14:37 UTC in Recovery, a minor safety event occurred involving verbal order handover. The incident was assigned preliminary risk score 16 in the Low band.
During procedural verification in Recovery at 14:37, team identified that verbal order handover 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.
Top Similar Incidents in Surgical
Semantic similarity calculated across category, location, and clinical narrative keywords.
Documentation variance (Verbal order handover) in Recovery
Documentation variance (Verbal order handover) in Recovery
Documentation variance (Verbal order handover) in Recovery
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 (4)
Masked by default per governance protocolHandover & Action Notes (2)
Attending physician notified. Urgent plain film radiography reviewed; no cortical breach identified.
Attending physician notified. Urgent plain film radiography reviewed; no cortical breach identified.