Medication reconciliation failure on transfer from Emergency to Ward 4A
Omission of anti-hypertensive dose on transfer; patient blood pressure spiked to 175/105 mmHg, rectified within 4 hours without permanent harm.
Incident Timeline Coverage Discontinuity
Unrecorded intervals exceeding standard reporting windows detected in the incident sequence.
Multidisciplinary Ishikawa Fishbone Diagram
Systemic root cause analysis across People, Process, Equipment, Environment, Management, and Materials.
5 Whys Root Cause Logic Chain
Sequential causal deduction terminating in institutional SOP and process vulnerabilities.
Why?Why was the medication reconciliation missed?
The receiving ward nurse did not see the medication order during transfer.
Why?Why was the medication order not seen?
The medication order was documented in the ED emergency chart instead of the inpatient transfer module.
Why?Why was it documented in the emergency chart?
The transfer workflow was completed before the pharmacist reconciliation step was marked done.
Why?Why was transfer completed before reconciliation?
The hospital transfer SOP had no hard-stop or prerequisite check for medication reconciliation.
Why?Why was there no hard-stop in the SOP?
Medication reconciliation was integrated into neither the transfer SOP nor the hospital EMR workflow system.