Procedural safety observation (Anesthesia delayed induction) in Ward 4C
Occurred: 2025-04-08T10:35 UTC · Reported: 2025-04-12T20:35 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 10:35 UTC in Ward 4C, a near miss safety event occurred involving anesthesia delayed induction. The incident was assigned preliminary risk score 11 in the Low band.
In Ward 4C at 10:35, surgical team conducting safety checklist noted a variance relating to anesthesia delayed induction. Formal pause was executed.
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 Jonathan Ray on 2025-04-12.
"Clinical assessment downgraded: immediate mitigating intervention prevented systemic patient exposure."
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Procedural safety observation (Anesthesia delayed induction) in Ward 4C
Procedural safety observation (Anesthesia delayed induction) in Ward 4C
Procedural safety observation (Anesthesia delayed induction) 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 surgical & invasive procedures: standardized protocol enforcement and hardware interlock.
Parties Involved (3)
Masked by default per governance protocolHandover & Action Notes (2)
Discussed case at weekly multi-disciplinary quality committee; escalated to departmental risk register.
Discussed case at weekly multi-disciplinary quality committee; escalated to departmental risk register.