SIQ-2026-007
Open
Severity: Clinical process
Raised: 14 Apr 2026Post-operative surgical site infection cluster in General Surgery Ward 3B
Cluster of 3 superficial surgical site infections identified within 72 hours post-laparotomy in Ward 3B. Wound swabs sent for culture; wound care upgraded.
RCA Investigation LeadDr. Tan Mei LingInfection Control Officer & Consultant Microbiologist
Ishikawa Category Blind Spots (6 unpopulated)
The multidisciplinary investigation has not recorded contributing factors across People, Process, Equipment, Environment, Management, Materials.
People Focus:Human factors, clinical handover gaps, fatigue, task allocation during peak shift transitions
Process Focus:SOP ambiguity, safety checklist execution, verification hard-stops, timeout workflow
Equipment Focus:Hardware reliability, battery backup, monitor display artifacts, calibration schedules
Environment Focus:Department bed occupancy, ambient noise, emergency surge overcrowding, workspace ergonomics
Management Focus:Staffing ratio, senior supervision on call, escalation protocol, leadership oversight
Materials Focus:Paper vs digital form standardized fields, drug label packaging, reagent batch consistency
Derived from 6M multidisciplinary cause distributionGovernance disclosure (1.4.1.4)
Case Closure Evidence Maturity
Case file is advancing through resolution stages. 4 closure criteria remain pending formal clinical governance audit records.
Ratification is gated until all four mandatory criteria have verified completion logs.
Derived from statutory verification criteria readiness auditGovernance disclosure (1.4.1.4)
Multidisciplinary Ishikawa Fishbone Diagram
6-Category RCA
Systemic root cause analysis across People, Process, Equipment, Environment, Management, and Materials.
5 Whys Root Cause Logic Chain
Systemic Vulnerability Analysis
Sequential causal deduction terminating in institutional SOP and process vulnerabilities.
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Step 1 — Pending deeper RCA committee panel drill-down...
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Step 2 — Pending deeper RCA committee panel drill-down...
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Step 3 — Pending deeper RCA committee panel drill-down...
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Step 4 — Pending deeper RCA committee panel drill-down...
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Step 5 — Pending deeper RCA committee panel drill-down...
Statutory Obligation Clock
MSQH 6-Stage Resolution TimelineOn Track
Active Stage: SIQ Form Submission52.3 hours remaining
Due: 17 Apr 2026, 07:00 am
Lifecycle Progression
1
SIQ Form SubmissionStatutory due 2026-04-17
52.3h left
2
Root Cause AnalysisStatutory due 2026-04-28
316.3h left
3
Corrective Action PlanStatutory due 2026-05-15
724.3h left
4
Verification & MonitoringStatutory due 2026-07-15
2188.3h left
5
Case ClosureStatutory due 2026-08-15
2932.3h left