egress_inspection_v4.dcm

Owner: Dr. Elena Rostova

Uploaded: 27 Aug 2026

Version: v4

Size: 570.8 MB

0%Quality

Document Gaps Summary:3 Gaps FoundCritical: 1Major: 1Minor: 1

Quality Assessment

This document is missing an explicit revision cadence or committee approval stamp, which a surveyor will typically ask for.

Classification:egress inspection

Effective year:2023

Review due:Q2 2027

What this document proves

Measurable element alignments and explainability trace

MMU.1Major Gap (F-0238)

Medication use organised and governed by a responsible pharmacy structure (paraphrased)

MMU.1

egress_inspection_v4.dcm

Documented Policy Evidence

Verification Gap Detected

MMU.3Critical Gap (F-0142)

Medication storage, labelling and independent double-check before administration (paraphrased)

MMU.3

egress_inspection_v4.dcm

Documented Policy Evidence

Verification Gap Detected

Open findings related to this document (3)

critical

F-0142

Open

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.3

high

F-0238

awaiting-verification

Evidence gap identified for MMU.1 during mock surveyor; requires documented remediation. (demonstration)

Target requirement: MMU.1

low

F-0253

Open

Evidence gap identified for MMU.1 during mock surveyor; requires documented remediation. (demonstration)

Target requirement: MMU.1