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id
stringclasses
6 values
case_title
stringclasses
6 values
cascade_summary
stringclasses
6 values
safety_checkpoints_expected
stringclasses
6 values
interruption_points_observed
stringclasses
6 values
failed_interruption_points
stringclasses
6 values
recovery_opportunities_lost
stringclasses
6 values
normalization_of_deviance_flags
stringclasses
6 values
authority_gradient_effects
stringclasses
6 values
resilience_gap_index
float64
0.7
0.82
preventability_score
float64
0.68
0.85
minimal_system_fix_set
stringclasses
6 values
notes
stringclasses
6 values
constraints
stringclasses
1 value
gold_checklist
stringclasses
1 value
SCBA-001
Vancomycin nephrotoxicity cascade
Cr rise -> oliguria -> overload -> ICU
renal dose check; 24h labs; pharmacist review
24h labs done; no action
24h lab review; dose adjustment; stop nephrotoxin
early de-escalation; fluid management before overload
routine acceptance of rising Cr
junior nurse concern dismissed
0.78
0.8
hard stop on Cr rise; pharmacist signoff; escalation rule
System had multiple chances
Under 320 words.
failed+gap+fix
SCBA-002
Contrast AKI escalation
contrast -> AKI -> hypotension -> ICU
hydration protocol; post-contrast labs
labs delayed; dehydration ignored
pre-scan hydration; post-scan monitoring
alternate imaging; early fluids
contrast ordered as default
radiology risk note not acted on
0.72
0.7
contrast risk gate; hydration bundle; eGFR hard rule
Default pathway failed
Under 320 words.
failed+gap+fix
SCBA-003
Opioid respiratory collapse
sedation -> CO2 retention -> hypoxia
sedation scoring; capnography high-risk
sedation scored; no escalation
sedation escalation trigger; dose reduction
early naloxone; switch analgesia
sleeping patient assumed stable
nurse escalation blocked by hierarchy
0.82
0.85
capnography for COPD; mandatory sedation trigger; rapid review
Classic monitoring failure
Under 320 words.
failed+gap+fix
SCBA-004
C. diff systemic decline
antibiotics -> diarrhea -> AKI -> sepsis
antibiotic review day3; stool trigger policy
diarrhea noted; minimized
antibiotic stop review; early stool testing
early isolation; fluids; stewardship consult
diarrhea treated as nuisance
stewardship advice deferred
0.74
0.75
day3 antibiotic stop rule; diarrhea escalation protocol
Slow drift not interrupted
Under 320 words.
failed+gap+fix
SCBA-005
Anticoagulation bleed cascade
bleed -> anemia -> hypotension -> fall
renal dosing check; Hb monitoring
Hb low; no action
dose verification; early bleed workup
hold DOAC; gastro eval
bruising normalized
family concerns discounted
0.7
0.68
dose gate by eGFR; Hb trigger; fall-risk plan
Multiple weak signals ignored
Under 320 words.
failed+gap+fix
SCBA-006
Line infection escalation
line kept -> bacteremia -> shock
daily line necessity review; site inspection
site checked; tenderness missed
daily removal decision; asepsis audit
early removal; culture earlier
lines left for convenience
junior staff not empowered to remove
0.76
0.78
mandatory daily line check; empower removal; checklist audit
Maintenance system failed
Under 320 words.
failed+gap+fix

What this dataset tests

Whether an intelligence system can explain
why a clinical system failed to self-correct
during an iatrogenic harm cascade.

Required outputs

  • failed interruption points
  • recovery opportunities lost
  • resilience gap index
  • normalization of deviance flags
  • authority gradient effects
  • preventability score
  • minimal system fix set

Use case

Third layer of the Iatrogenic Harm Cascade Library.

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