Process discrepancy (Specimen mislabeling) in Triage
Occurred: 2025-03-17T09:09 UTC · Reported: 2025-03-20T15:09 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 09:09 UTC in Triage, a near miss safety event occurred involving specimen mislabeling. The incident was assigned preliminary risk score 11 in the Low band.
During shift changeover in Triage at 09:09, staff flagged a variance regarding specimen mislabeling. Escalation was enacted according to protocol.
Risk Evaluation & Score Breakdown
Deterministic multi-term risk score from 1 to 100 derived from clinical harm, recurrence, and reporting lag.
Score overridden from 11 to 1 by Dr. Thomas Keller on 2025-03-20.
"Clinical assessment downgraded: immediate mitigating intervention prevented systemic patient exposure."
Top Similar Incidents in Emergency
Semantic similarity calculated across category, location, and clinical narrative keywords.
Process discrepancy (Specimen mislabeling) in Triage
Process discrepancy (Specimen mislabeling) in Triage
Process discrepancy (Specimen mislabeling) in Triage
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 clinical process & handover: standardized protocol enforcement and hardware interlock.
Parties Involved (4)
Masked by default per governance protocolHandover & Action Notes (2)
Biomedical service checked unit. Error code reset after capacitor swap; recalibration certificate issued.
Biomedical service checked unit. Error code reset after capacitor swap; recalibration certificate issued.