egress_inspection_v4.xlsx
Quality Assessment
This document satisfies the core requirement baseline but would benefit from a refreshed review signature before survey.
What this document proves
Measurable element alignments and explainability trace
Medication use organised and governed by a responsible pharmacy structure (paraphrased)
Medication storage, labelling and independent double-check before administration (paraphrased)
Prescribing and ordering governed by defined, authorised processes (paraphrased)
Independent double-check for high-alert medications not consistently performed at administration; self-assessment claimed 94% but evidence supports 71% and observed practice 68%.
Target requirement: MMU.3Evidence gap identified for MMU.4 during mock surveyor; requires documented remediation. (demonstration)
Target requirement: MMU.4Evidence gap identified for MMU.1 during mock surveyor; requires documented remediation. (demonstration)
Target requirement: MMU.1Evidence gap identified for MMU.1 during mock surveyor; requires documented remediation. (demonstration)
Target requirement: MMU.1Evidence gap identified for MMU.4 during document analysis; requires documented remediation. (demonstration)
Target requirement: MMU.4