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Metropolitan General Hospital · 420 beds

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INC-2026-0049·Closed

Patient fall event (Unassisted mobilization) in Ward 4C

Occurred: 2025-03-15T23:08 UTC · Reported: 2025-03-19T21:08 UTC

17Low
DepartmentGeneral Medicine
Unit & RoomWard 4C · Bay 2
Harm Levelminor
Patient ReferencePT-1049

Clinical Narrative & Synthesized Abstract

Synthesized Abstract: At 23:08 UTC in Ward 4C, a minor safety event occurred involving unassisted mobilization. The incident was assigned preliminary risk score 17 in the Low band.

Patient slipped in Ward 4C at 23:08 during unassisted mobilization. Staff were in close proximity and assisted the patient immediately.

Strong signal(92%)|Because:
What this could not see: Informal verbal handover notes prior to admission are unrecorded

Risk Evaluation & Score Breakdown

Deterministic multi-term risk score from 1 to 100 derived from clinical harm, recurrence, and reporting lag.

Harm Base Score+12
Patients Affected+0
Recurrence in Window+0
Department Baseline+2
Detection Lag+3
External Reportability+0

Top Similar Incidents in General Medicine

Semantic similarity calculated across category, location, and clinical narrative keywords.

3 matches
INC-2026-0289100% match

Patient fall event (Unassisted mobilization) in Ward 4C

Ward 4C2025-05-04
INC-2026-1369100% match

Patient fall event (Unassisted mobilization) in Ward 4C

Ward 4C2025-12-18
INC-2026-1609100% match

Patient fall event (Unassisted mobilization) in Ward 4C

Ward 4C2026-02-07

Root Cause Analysis & Safeguards Workspace

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Explore 5 Whys causal pathways, 6-bone fishbone decomposition, and barrier analysis safeguards.

Corrective & Preventive Actions (1)

CAPA-2026-0049training TierDue: 2025-01-20

Implement systemic safeguard against patient falls: standardized protocol enforcement and hardware interlock.

closed

Parties Involved (4)

Masked by default per governance protocol
reporterreporter [Masked]
patientPatient 0132
involved staffStaff Member [0133]
witnesswitness [Masked]

Handover & Action Notes (2)

Patient and family briefed by consultant regarding sequence of events; open disclosure logged.

Clinician F. Anderson (Frontline staff)2025-03-19T21:08 UTC

Patient and family briefed by consultant regarding sequence of events; open disclosure logged.

Nurse Samuel Osei (Frontline staff)2025-03-19T21:08 UTC