1 similar incident recorded in department 90-day window
Hardware error code on Fresenius Kabi Agilia (Unit #I-303) in Medical Day Unit
Occurred: 2025-03-15T16:09 UTC · Reported: 2025-03-20T05:09 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 16:09 UTC in Medical Day Unit, a none safety event occurred involving infusion pump malfunction. The incident was assigned preliminary risk score 14 in the Low band.
At 16:09, an infusion pump (Fresenius Kabi Agilia (Unit #I-303)) triggered an unresolvable error code 'ERR-04' during active maintenance fluid delivery. The device ceased delivery without audio alarm sounding for approximately 12 minutes.
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 medical equipment & devices: standardized protocol enforcement and hardware interlock.
Parties Involved (1)
Masked by default per governance protocolHandover & Action Notes (2)
Spoke with night NUM. Replacement harness fitted. Ward Sister confirms sensor mat returned to bed.
Spoke with night NUM. Replacement harness fitted. Ward Sister confirms sensor mat returned to bed.