Documentation variance (Unsigned protocol) in Ward 4C
Occurred: 2025-03-23T15:23 UTC · Reported: 2025-03-28T10:23 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 15:23 UTC in Ward 4C, a severe safety event occurred involving unsigned protocol. The incident was assigned preliminary risk score 63 in the Severe band.
During procedural verification in Ward 4C at 15:23, team identified that unsigned protocol was incomplete prior to commencement. Protocol was paused until validation was secured.
Risk Evaluation & Score Breakdown
Deterministic multi-term risk score from 1 to 100 derived from clinical harm, recurrence, and reporting lag.
Score overridden from 63 to 51 by Eng. David O'Connor on 2025-03-28.
"Clinical assessment downgraded: immediate mitigating intervention prevented systemic patient exposure."
Top Similar Incidents in General Medicine
Semantic similarity calculated across category, location, and clinical narrative keywords.
Documentation variance (Unsigned protocol) in Ward 4C
Documentation variance (Unsigned protocol) in Ward 4C
Documentation variance (Unsigned protocol) in Ward 4C
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 documentation & consent: 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.