Accreditation War Room

Top risks going into the window

• criticalTwo-identifier check not consistently verbalised before specimen collectionEmergency — Silent verification removes the patient from the safety check and is a common trigger for surveyor deep-dive into identification practice hospital-wide.
• highICU competency assessments overdue for 14 nursesICU — Expired competency records are objective, easily-evidenced deficiencies that surveyors can identify from a staff file sample in minutes.
• highStaff unable to demonstrate medication reconciliation at transferPharmacy — Unreconciled medication at transfer is a leading contributor to preventable adverse drug events, and surveyors routinely trace this at the point of care rather than in policy.
• highHazardous materials storage lacks current labelling in OR sterile storeSurgery — Unlabelled hazardous materials create direct staff exposure risk and are highly visible during environmental tours.
• mediumHandover tool not used consistently between ED and inpatient wardsNursing — Incomplete handover of pending results is a frequent cause of delayed diagnosis and is traced across the full patient journey.