Process discrepancy (Specimen mislabeling) in Pod B
Occurred: 2025-04-11T15:46 UTC · Reported: 2025-04-16T01:46 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 15:46 UTC in Pod B, a none safety event occurred involving specimen mislabeling. The incident was assigned preliminary risk score 6 in the Low band.
During shift changeover in Pod B at 15:46, 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 6 to 1 by Rachel Stern on 2025-04-16.
"Clinical assessment downgraded: immediate mitigating intervention prevented systemic patient exposure."
Top Similar Incidents in ICU
Semantic similarity calculated across category, location, and clinical narrative keywords.
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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 clinical process & handover: standardized protocol enforcement and hardware interlock.
Parties Involved (3)
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.