Equipment discrepancy (Monitor battery failure) in Ward 4C
Occurred: 2025-04-21T09:20 UTC · Reported: 2025-04-25T09:20 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 09:20 UTC in Ward 4C, a near miss safety event occurred involving monitor battery failure. The incident was assigned preliminary risk score 11 in the Low band.
Staff in Ward 4C identified that clinical equipment experienced monitor battery failure at 09:20. Clinical team verified patient safety and swapped device.
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 Dr. Benjamin Cole on 2025-04-25.
"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.
Equipment discrepancy (Monitor battery failure) in Ward 4C
Equipment discrepancy (Monitor battery failure) in Ward 4C
Equipment discrepancy (Monitor battery failure) 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 medical equipment & devices: 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.