Enterprise Safety Management

Vectis Safety

When Something Goes Wrong,
Get to Why It Happened.

A full suite for healthcare safety — event reporting, EMR-grounded root cause analysis, and living risk registers — purpose-built for organizations that take learning from failure seriously.

01

Safety Reporting System

A structured, low-friction way for staff at any level to report safety events, near misses, and unsafe conditions. Designed to maximize reporting volume — because every event you don't hear about is a learning opportunity lost.

Event Reporting Near Misses Anonymous Mobile-Ready
02

RCA Management

Run structured root cause analyses with built-in frameworks — fishbone, 5 Whys, fault tree, contributing factors. Capture the full investigation, surface contributing factors, and translate findings into action plans that close.

Fishbone 5 Whys Fault Tree Action Plans
03

Risk Management

Identify, score, and track operational risks proactively. Maintain a living risk register with severity, likelihood, and ownership — and link mitigation efforts directly to active improvement projects in Vectis Ops.

Risk Register Severity Scoring Mitigation Tracking FMEA

Most safety events are reported, investigated, and forgotten.

Reports fragment across email, paper forms, and ticketing systems. Root cause analyses get filed away. Risk registers age out of relevance. Action plans don't close. The lessons exist — they just don't transfer.

Vectis Safety captures the full lifecycle of a safety event in one place: from the moment an issue is reported, through structured investigation, through corrective action, all the way back into operational improvement. Nothing is lost. Patterns become visible. Learning compounds.

Designed to integrate directly with Vectis Ops — so when an RCA recommends process change, that change becomes a tracked improvement project with PDSA cycles, run charts, and accountability built in.

Vectis Safety Maskedsafety v2.1.0 · us-east-1

Program overview

Notional data only

Safety event portfolio, review throughput, and how agent findings hold up under adjudication.

Classified Events
4
harm score + factors on record
Unclassified
1
no harm score yet
In Review Queue
4
2 past the 21-day commitment
Avg Turnaround
12.4 d
report → sign-off · target 21 d
Facts Confirmed
53%
17 of 32 agent findings
Agent Finding Adjudicationrolling 90 d · 32 findings
Confirmed against the record1753%
Needs further detail or interview516%
Incorrect — not supported by the record26%
Not yet adjudicated825%

Incorrect findings are fed back to the agent configuration weekly. A rate above 10% triggers a review of the retrieval scope before drafts are trusted for triage.

Turnaround by Stage
Intake → draft0.4 d
Triage2.1 d
Adjudication5.8 d
Team interviews3.6 d
Sign-off0.5 d

Median 9.5 d. Two events are past the 21-day committee commitment, both awaiting team interviews.

Events by ClassificationNCC MERP · reviewer-assigned
EventSummaryHarmFacts C/N/IStageAge
SE-****-**13 Lisinopril restart at 7.5× prior dose → Stage 3 oliguric AKI Unclassified 0/0/0In review15 d
SE-****-**08 Vancomycin trough not drawn across three consecutive doses Cat E 4/2/0Triage11 d
SE-****-**01 Insulin infusion programmed at 10× ordered rate, caught at 40 min Cat F 5/1/1Awaiting sign-off19 d
SE-****-**96 Heparin flush concentration mix-up, no patient harm Cat C 3/2/0In review6 d
SE-****-**89 Delayed sepsis escalation on overnight shift Cat F 5/0/1Closed18 d

Notional data shown. Event IDs and patient identifiers are masked in every reviewer view; findings link back to the source record for anyone with case access.

Every timeline, grounded in the record.

When a patient was reintubated 19 hours after extubation, Vectis Safety reconstructed the chronology directly from the EMR — timestamps, orders, and unacknowledged alerts — and reviewed eight salient-factor categories, flagging what the data could and could not assess. Investigations can be powered by Vectis Copilot, so every finding is traceable to a table, column, and record ID.

Findings — Chronology

D3 07:40
Extubated to HFNC 8 L/min after a 2 h spontaneous breathing trial. Cuff-leak not documented.
D3 09:15
Dexmedetomidine stopped with no wean order. Last scheduled steroid 34 h prior.
D3 14:20
RR rises to 46 (baseline 28); SpO₂ 93% on FiO₂ 0.45. No respiratory reassessment for 4 h 40 min.
D3 19:05
Nurse-driven escalation criteria met. Deterioration BPA fired; no acknowledgement recorded.
D3 22:30
Shift handoff. Capillary gas pH 7.28 / pCO₂ 58 resulted 22:51; first note referencing it at 01:40.
D4 02:44
Reintubated (7.0 cuffed, grade 1 view) — 19 h 4 min post-extubation.

Salient Factors Reviewed — Eight Categories

Observed

Patient Factors

Trisomy 21, prior prolonged intubation (2023), baseline OSA.

Observed

Clinical Presentation

RR trend and pCO₂ rise across the 12 h before the event.

Observed

Medications

Abrupt dexmedetomidine stop; no peri-extubation steroid.

Checked — No Signal

Procedures / Interventions

No delayed or cancelled orders in the window.

Observed

Care Team / Workflow

Gas resulted 22:51, first referenced 01:40 — across a handoff boundary.

Observed

Monitoring / Documentation

4 h 40 min respiratory-assessment gap; BPA unacknowledged.

Observed

Protocol Adherence

Extubation-readiness bundle: 3 of 5 elements documented.

Not Assessable

System / Environmental

Staffing ratios are absent from the source database.

1
Report

A staff member observes or experiences a safety event, near miss, or unsafe condition. They submit a structured report — anonymously if needed — in under two minutes from any device.

2
Triage

Reports are routed to the appropriate safety officer or department lead. Severity, harm classification, and immediate response actions are captured in a structured format that supports both individual triage and aggregate trend analysis.

3
Investigate

For events warranting deeper analysis, an RCA is launched using a structured framework — fishbone, 5 Whys, fault tree, or contributing factor analysis. Investigators capture timeline, contributing factors, and root cause hypotheses in one place.

4
Act

RCA findings translate directly into corrective action plans — with named owners, due dates, and verification criteria. Significant findings can be promoted into structured improvement projects in Vectis Ops with full PDSA tracking.

5
Learn

Patterns across reports, RCAs, and risk registers become visible — by department, time period, event type, and contributing factor. The organization moves from reactive incident response to proactive risk reduction.

Four products. One system.

Ask the question, run the improvement, prove the outcome, protect the patient — the Vectis suite closes the loop.

See It on Your Own Events.

Vectis Safety is running today for healthcare safety teams. Get in touch for a walkthrough on your own event data, or to discuss integration with your EMR and existing reporting infrastructure.

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