Process discrepancy (Specimen mislabeling) in MRI Unit
Occurred: 2025-05-07T22:25 UTC · Reported: 2025-05-12T00:25 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 22:25 UTC in MRI Unit, a near miss safety event occurred involving specimen mislabeling. The incident was assigned preliminary risk score 8 in the Low band.
During shift changeover in MRI Unit at 22:25, staff flagged a variance regarding specimen mislabeling. Escalation was enacted according to 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 8 to 1 by Nurse Kevin Doyle on 2025-05-12.
"Clinical assessment downgraded: immediate mitigating intervention prevented systemic patient exposure."
Top Similar Incidents in Radiology
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Process discrepancy (Specimen mislabeling) in MRI Unit
Process discrepancy (Specimen mislabeling) in MRI Unit
Process discrepancy (Specimen mislabeling) in MRI Unit
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 process & handover: 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.