Medication management and use
Assesses hospital governance, standardized clinical protocols, staff adherence, and documented evidentiary compliance for medication management and use.
Trend Direction
down (-3%)
Identified compliance findings in MMU (10)
Independent double-check for high-alert medications not consistently performed at administration; self-assessment claimed 94% but evidence supports 71% and observed practice 68%.
Evidence gap identified for MMU.4 during mock surveyor; requires documented remediation. (demonstration)
Evidence gap identified for MMU.6 during live field capture; requires documented remediation. (demonstration)
Evidence gap identified for MMU.1 during mock surveyor; requires documented remediation. (demonstration)
Evidence gap identified for MMU.6 during document analysis; requires documented remediation. (demonstration)
Evidence gap identified for MMU.7 during learner evaluation; requires documented remediation. (demonstration)
Evidence gap identified for MMU.5 during live field capture; requires documented remediation. (demonstration)
Evidence gap identified for MMU.6 during mock surveyor; requires documented remediation. (demonstration)
Evidence gap identified for MMU.1 during mock surveyor; requires documented remediation. (demonstration)
Evidence gap identified for MMU.4 during document analysis; requires documented remediation. (demonstration)
Requirements & Measurable Elements
22 total requirementsRequirement | Standard text (paraphrased) | Criticality | Measurable Elements | Status |
|---|---|---|---|---|
| MMU.1 | Medication use organised and governed by a responsible pharmacy structure (paraphrased) policyorg-chart | high | 4 of 5 met70% | Partial |
| MMU.3 | Medication storage, labelling and independent double-check before administration (paraphrased) policytrainingobservationaudit | critical | 4 of 6 met61% | Gap |
| MMU.4 | Prescribing and ordering governed by defined, authorised processes (paraphrased) policyaudit | high | 2 of 3 met66% | Partial |
| MMU.5 | Preparation and dispensing performed in a clean, controlled manner (paraphrased) policyobservation | high | 3 of 5 met68% | Partial |
| MMU.6 | Administration verified against order with independent second check for high-alert drugs (paraphrased) trainingobservationaudit | critical | 4 of 6 met59% | Gap |
| MMU.7 | Medication effects monitored and adverse events reported (paraphrased) policyreports | medium | 2 of 3 met74% | Partial |
| MMU.8 | Medication management and use — control 8: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 4 met56% | Gap |
| MMU.9 | Medication management and use — control 9: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met51% | Gap |
| MMU.10 | Medication management and use — control 10: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 4 of 5 met72% | Partial |
| MMU.11 | Medication management and use — control 11: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 4 met54% | Gap |
| MMU.12 | Medication management and use — control 12: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 5 met68% | Partial |
| MMU.13 | Medication management and use — control 13: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 6 met54% | Gap |
| MMU.14 | Medication management and use — control 14: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 2 of 3 met65% | Partial |
| MMU.15 | Medication management and use — control 15: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 4 met47% | Gap |
| MMU.16 | Medication management and use — control 16: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 2 of 3 met63% | Gap |
| MMU.17 | Medication management and use — control 17: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 2 of 4 met51% | Gap |
| MMU.18 | Medication management and use — control 18: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | high | 2 of 3 met65% | Partial |
| MMU.19 | Medication management and use — control 19: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 5 of 6 met77% | Partial |
| MMU.20 | Medication management and use — control 20: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | critical | 3 of 4 met71% | Partial |
| MMU.21 | Medication management and use — control 21: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 2 of 3 met73% | Partial |
| MMU.22 | Medication management and use — control 22: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | low | 4 of 6 met71% | Partial |
| MMU.23 | Medication management and use — control 23: documented process, responsible owner and evidence of practice (paraphrased) policyaudit | medium | 3 of 4 met73% | Partial |