Incorrect dosage administration of Heparin sodium in Central Dispensary
Occurred: 2025-03-14T06:22 UTC · Reported: 2025-03-18T11:22 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 06:22 UTC in Central Dispensary, a near miss safety event occurred involving dosing error. The incident was assigned preliminary risk score 10 in the Low band.
During the morning medication round at 06:22, nursing staff identified that Heparin sodium was prepared at a concentration exceeding prescribed chart dosage. Verification against the EMR chart revealed an order transcription variance. The infusion was suspended prior to complete administration.
Risk Evaluation & Score Breakdown
Deterministic multi-term risk score from 1 to 100 derived from clinical harm, recurrence, and reporting lag.
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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 (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.