Clinical Root Cause Investigations

Patient unassisted fall in Ward 4C en-suite bathroom

Equipment discrepancy (Tubing misconnection) in Sterile Supply (CSSD)

Documentation variance (Verbal order handover) in General X-Ray

Infection protocol variance (Hand hygiene non-compliance) in Sterile Compounding

Process discrepancy (Delayed escalation) in Sterile Supply (CSSD)

Procedural safety observation (Anesthesia delayed induction) in Ward 4B

Environmental safety hazard (Hazardous waste disposal) in Ambulatory

Medication protocol variance (Wrong route) in NICU

Patient fall event (Unassisted mobilization) in Labour & Delivery

Hardware error code on Braun Space Infusomat (Unit #M-109) in Acute Care

Documentation variance (Unsigned protocol) in Sterile Supply (CSSD)

Infection protocol variance (PPE degradation) in Haematology

Process discrepancy (Critical lab value delayed) in Biochemistry

Procedural safety observation (Surgical site verification) in Ultrasound

Environmental safety hazard (Spill or wet floor slip) in Labour & Delivery

Flow rate programming variance on Becton Dickinson Alaris Guardrails (Unit #S-412) in Resus

Patient fall event (Call-bell delay) in Aseptic Unit

Equipment discrepancy (Calibration lapsed) in Central Dispensary

Documentation variance (EMR allergy sync error) in Sterile Compounding

Infection protocol variance (Central line protocol lapse) in Resus

Process discrepancy (Specimen mislabeling) in Labour & Delivery

Procedural safety observation (Specimen labeling in theatre) in Sterile Compounding

Environmental safety hazard (Vaccine fridge temperature excursion) in General X-Ray

Incorrect dosage administration of Morphine sulfate in Biomedical Engineering

Unwitnessed patient fall from bedside in MRI Unit

Equipment discrepancy (Monitor battery failure) in Ultrasound

Documentation variance (Delayed discharge summary) in Ambulatory

Infection protocol variance (Isolation precaution breach) in Plant & Utilities

Process discrepancy (Shift handover omission) in Triage

Procedural safety observation (Surgical count discrepancy) in Biomedical Engineering

Environmental safety hazard (Emergency exit obstructed) in Ambulatory

Medication protocol variance (Wrong route) in Sterile Supply (CSSD)

Slip during commode transfer in Pod A

Equipment discrepancy (Alarm volume muted) in Postnatal Ward

Documentation variance (Missing procedure consent) in NICU

Infection protocol variance (Sharps needle stick) in Resus

Process discrepancy (Patient identification check) in Sterile Compounding

Procedural safety observation (Pre-op checklist lapse) in Acute Care

Environmental safety hazard (Water supply fluctuation) in Recovery

Flow rate programming variance on Becton Dickinson Alaris Guardrails (Unit #S-412) in Ward 2A

Patient fall event (Bathroom fall) in Medical Day Unit

Equipment discrepancy (Tubing misconnection) in Acute Care

Documentation variance (Verbal order handover) in Recovery

Infection protocol variance (Hand hygiene non-compliance) in Medical Day Unit

Process discrepancy (Delayed escalation) in Triage

Procedural safety observation (Anesthesia delayed induction) in Sterile Compounding

Environmental safety hazard (Hazardous waste disposal) in Blood Bank

Incorrect dosage administration of Heparin sodium in Central Dispensary

Patient fall event (Unassisted mobilization) in Ward 4C

Hardware error code on Fresenius Kabi Agilia (Unit #I-303) in Medical Day Unit