Equipment discrepancy (Monitor battery failure) in Ward 4C
Occurred: 2025-05-16T17:55 UTC · Reported: 2025-05-21T02:55 UTC
Clinical Narrative & Synthesized Abstract
Synthesized Abstract: At 17:55 UTC in Ward 4C, a none safety event occurred involving monitor battery failure. The incident was assigned preliminary risk score 8 in the Low band.
Staff in Ward 4C identified that clinical equipment experienced monitor battery failure at 17:55. 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 8 to 1 by Nurse Chloe Moreau on 2025-05-21.
"Clinical assessment downgraded: immediate mitigating intervention prevented systemic patient exposure."
Top Similar Incidents in General Medicine
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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 (2)
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.