Procedural safety observation (Anesthesia delayed induction) in Sterile Compounding
Occurred: 2025-03-14T16:34 UTC · Reported: 2025-03-18T23:34 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 16:34 UTC in Sterile Compounding, a minor safety event occurred involving anesthesia delayed induction. The incident was assigned preliminary risk score 17 in the Low band.
In Sterile Compounding at 16:34, surgical team conducting safety checklist noted a variance relating to anesthesia delayed induction. 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.
Score overridden from 17 to 5 by Pharm. Priya Nair on 2025-03-18.
"Clinical assessment downgraded: immediate mitigating intervention prevented systemic patient exposure."
Top Similar Incidents in Pharmacy
Semantic similarity calculated across category, location, and clinical narrative keywords.
Procedural safety observation (Anesthesia delayed induction) in Aseptic Unit
Procedural safety observation (Anesthesia delayed induction) in Central Dispensary
Procedural safety observation (Specimen labeling in theatre) in Sterile Compounding
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 (3)
Masked by default per governance protocolHandover & Action Notes (2)
Discussed case at weekly multi-disciplinary quality committee; escalated to departmental risk register.
Discussed case at weekly multi-disciplinary quality committee; escalated to departmental risk register.