Documentation variance (Unsigned protocol) in Postnatal Ward
Occurred: 2025-04-18T13:43 UTC · Reported: 2025-04-22T22:43 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 13:43 UTC in Postnatal Ward, a severe safety event occurred involving unsigned protocol. The incident was assigned preliminary risk score 60 in the Severe band.
During procedural verification in Postnatal Ward at 13:43, 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 60 to 48 by Dr. Eleanor Vance on 2025-04-22.
"Clinical assessment downgraded: immediate mitigating intervention prevented systemic patient exposure."
Top Similar Incidents in Maternity
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Documentation variance (Unsigned protocol) in Postnatal Ward
Documentation variance (Unsigned protocol) in Labour & Delivery
Documentation variance (Unsigned protocol) in Labour & Delivery
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.