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INC-2026-0271·Closed

Environmental safety hazard (Emergency exit obstructed) in General X-Ray

Occurred: 2025-04-30T09:20 UTC · Reported: 2025-05-03T12:20 UTC

30Moderate
DepartmentRadiology
Unit & RoomGeneral X-Ray · Bay 8
Harm Levelmoderate
Patient ReferencePT-1271

Clinical Narrative & Synthesized Abstract

Synthesized Abstract: At 09:20 UTC in General X-Ray, a moderate safety event occurred involving emergency exit obstructed. The incident was assigned preliminary risk score 30 in the Moderate band.

At 09:20 in General X-Ray, staff observed emergency exit obstructed presenting potential slip or operational hazard. Area was isolated.

Strong signal(92%)|Because:
What this could not see: Informal verbal handover notes prior to admission are unrecorded

Risk Evaluation & Score Breakdown

Deterministic multi-term risk score from 1 to 100 derived from clinical harm, recurrence, and reporting lag.

Harm Base Score+28
Patients Affected+0
Recurrence in Window+0
Department Baseline-1
Detection Lag+3
External Reportability+0
Human Clinical Override Active

Score overridden from 30 to 18 by Sister Beatrice Miller on 2025-05-03.

"Clinical assessment downgraded: immediate mitigating intervention prevented systemic patient exposure."

Top Similar Incidents in Radiology

Semantic similarity calculated across category, location, and clinical narrative keywords.

3 matches
INC-2026-0231100% match

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INC-2026-0991100% match

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Root Cause Analysis & Safeguards Workspace

Open Interactive RCA Workspace

Explore 5 Whys causal pathways, 6-bone fishbone decomposition, and barrier analysis safeguards.

Corrective & Preventive Actions (1)

CAPA-2026-0271training TierDue: 2025-08-30

Implement systemic safeguard against environmental safety: standardized protocol enforcement and hardware interlock.

closed

Parties Involved (4)

Masked by default per governance protocol
reporterreporter [Masked]
patientPatient 0743
involved staffStaff Member [0744]
witnesswitness [Masked]

Handover & Action Notes (2)

Biomedical service checked unit. Error code reset after capacitor swap; recalibration certificate issued.

Dr. Benjamin Cole (Executive)2025-05-03T12:20 UTC

Biomedical service checked unit. Error code reset after capacitor swap; recalibration certificate issued.

Clinician B. Rossi (Frontline staff)2025-05-03T12:20 UTC