Infection protocol variance (Hand hygiene non-compliance) in Medical Day Unit
Occurred: 2025-03-14T06:10 UTC · Reported: 2025-03-18T22:10 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 06:10 UTC in Medical Day Unit, a near miss safety event occurred involving hand hygiene non-compliance. The incident was assigned preliminary risk score 11 in the Low band.
Routine surveillance check in Medical Day Unit at 06:10 noted an issue involving hand hygiene non-compliance. The duty sister intercepted the procedure and rectified aseptic 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 General Medicine
Semantic similarity calculated across category, location, and clinical narrative keywords.
Infection protocol variance (Hand hygiene non-compliance) in Medical Day Unit
Infection protocol variance (Hand hygiene non-compliance) in Medical Day Unit
Infection protocol variance (Hand hygiene non-compliance) in Medical Day 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 infection prevention & control: standardized protocol enforcement and hardware interlock.
Parties Involved (2)
Masked by default per governance protocolHandover & Action Notes (2)
Root cause debrief conducted with morning nursing team. Focus on verbal order readback adherence.
Root cause debrief conducted with morning nursing team. Focus on verbal order readback adherence.