Infection protocol variance (Sharps needle stick) in Sterile Compounding
Occurred: 2025-04-15T09:31 UTC · Reported: 2025-04-19T03:31 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 09:31 UTC in Sterile Compounding, a moderate safety event occurred involving sharps needle stick. The incident was assigned preliminary risk score 42 in the High band.
Routine surveillance check in Sterile Compounding at 09:31 noted an issue involving sharps needle stick. The duty sister intercepted the procedure and rectified aseptic 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 42 to 30 by Fiona Gallagher on 2025-04-19.
"Clinical assessment downgraded: immediate mitigating intervention prevented systemic patient exposure."
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Infection protocol variance (Sharps needle stick) in Sterile Compounding
Infection protocol variance (Sharps needle stick) in Sterile Compounding
Infection protocol variance (Sharps needle stick) in Sterile Compounding
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 infection prevention & control: 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.