Flow rate programming variance on Fresenius Kabi Agilia (Unit #I-303) in Ward 4C
Occurred: 2025-04-27T08:40 UTC · Reported: 2025-05-01T04:40 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 08:40 UTC in Ward 4C, a severe safety event occurred involving pump rate programming. The incident was assigned preliminary risk score 62 in the Severe band.
At 08:40, primary nurse noted that an infusion on Fresenius Kabi Agilia (Unit #I-303) was running at 50 mL/hr instead of the chartered 25 mL/hr. The smart pump dose error reduction system limit was overridden during bed transfer. Total excess volume infused was approximately 35 mL.
Risk Evaluation & Score Breakdown
Deterministic multi-term risk score from 1 to 100 derived from clinical harm, recurrence, and reporting lag.
Score overridden from 62 to 50 by Tariq Mansour on 2025-05-01.
"Clinical assessment downgraded: immediate mitigating intervention prevented systemic patient exposure."
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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 medication & iv fluids: 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.