Gaps & findings register
Central hospital compliance ledger aggregating deficits, missing evidence, and non-conformities across all 5 readiness solutions.
Identified across all 5 readiness solutions
Immediate survey risk requiring CAP
Active across clinical departments
33% resolution verification rate
Filter by originating readiness solution
5 solutions connectedID | Severity | Origin Solution | Requirement | Deficit Description & Location | Owner | Status |
|---|---|---|---|---|---|---|
| F-0142 | critical | Tracer | MMU.3 (MMU) | Independent double-check for high-alert medications not consistently performed at administration; self-assessment claimed 94% but evidence supports 71% and observed practice 68%. Dept: Pharmacy·Due: 21 Sep 2026·✓ Verified resolution | Dr. Fatima Al-Mansoor | Open |
| F-0119 | high | 360° Walkthrough | PCI.5 (PCI) | Hand-hygiene dispenser empty at ICU bay 4; compliance monitoring gaps in evening shift. Dept: ICU·Due: 23 Aug 2026 | Dr. Fatima Al-Mansoor | In progress |
| F-0203 | critical | 360° Walkthrough | FMS.4 (FMS) | Fire exit on level 3 obstructed by stored equipment during walkthrough. Dept: Facilities·Due: 25 Aug 2026 | Dr. Lucas Dubois | awaiting-verification |
| F-0188 | high | Document intelligence | PCI.8 (PCI) | Sharps container observed above the fill line; disposal policy lacks defined replacement threshold. Dept: ICU·Due: 30 Aug 2026·✓ Verified resolution | Dr. Mateo Hernandez | In progress |
| F-0090 | medium | Self-assessment | IPSG.1 (IPSG) | Patient identification narrative present but evidence of audit cadence missing for two units. Dept: Emergency·Due: 20 Aug 2026 | Dr. Mateo Hernandez | Open |
| F-0151 | medium | Staff competency | IPSG.6 (IPSG) | Fall-risk reassessment knowledge strong but observed documentation inconsistent. Dept: Maternity·Due: 30 Sep 2026·✓ Verified resolution | Dr. Elena Rostova | awaiting-verification |
| F-0210 | high | Document intelligence | FMS.8 (FMS) | Several equipment calibration labels expired; CMMS records not reconciled with floor inventory. Dept: Biomedical·Due: 28 Sep 2026 | Dr. Priya Sharma | Open |
| F-0227 | low | Staff competency | SQE.14 (SQE) | Evidence gap identified for SQE.14 during learner evaluation; requires documented remediation. (demonstration) Dept: Paediatrics·Due: 18 Sep 2026 | Dr. Mateo Hernandez | Open |
| F-0228 | high | Tracer | MMU.4 (MMU) | Evidence gap identified for MMU.4 during mock surveyor; requires documented remediation. (demonstration) Dept: Infection Prevention·Due: 27 Oct 2026 | Dr. Priya Sharma | Open |
| F-0229 | medium | 360° Walkthrough | IPSG.2 (IPSG) | Evidence gap identified for IPSG.2 during live field capture; requires documented remediation. (demonstration) Dept: Quality·Due: 29 Aug 2026 | Dr. Julian Mercier | In progress |
| F-0230 | critical | Document intelligence | SQE.14 (SQE) | Evidence gap identified for SQE.14 during document analysis; requires documented remediation. (demonstration) Dept: Operating Theatres·Due: 26 Sep 2026 | Dr. Elena Rostova | Open |
| F-0231 | medium | Self-assessment | SQE.5 (SQE) | Evidence gap identified for SQE.5 during self-assessment; requires documented remediation. (demonstration) Dept: Radiology·Due: 29 Aug 2026·✓ Verified resolution | Dr. Kwame Asante | Open |
| F-0232 | low | Staff competency | IPSG.1 (IPSG) | Evidence gap identified for IPSG.1 during learner evaluation; requires documented remediation. (demonstration) Dept: Dialysis·Due: 22 Sep 2026 | Dr. Sofia Rossi | Open |
| F-0233 | medium | Tracer | PCI.5 (PCI) | Evidence gap identified for PCI.5 during mock surveyor; requires documented remediation. (demonstration) Dept: Facilities·Due: 26 Sep 2026 | Dr. Lucas Dubois | awaiting-verification |
| F-0234 | medium | 360° Walkthrough | MMU.6 (MMU) | Evidence gap identified for MMU.6 during live field capture; requires documented remediation. (demonstration) Dept: Emergency·Due: 29 Sep 2026 | Dr. Fatima Al-Mansoor | Open |
| F-0235 | high | Document intelligence | IPSG.4 (IPSG) | Evidence gap identified for IPSG.4 during document analysis; requires documented remediation. (demonstration) Dept: Pharmacy·Due: 30 Oct 2026·✓ Verified resolution | Dr. Ingrid Lindqvist | Open |
| F-0236 | critical | Self-assessment | PCI.5 (PCI) | Evidence gap identified for PCI.5 during self-assessment; requires documented remediation. (demonstration) Dept: Maternity·Due: 29 Sep 2026 | Dr. Amara Okafor | In progress |
| F-0237 | low | Staff competency | FMS.4 (FMS) | Evidence gap identified for FMS.4 during learner evaluation; requires documented remediation. (demonstration) Dept: Outpatients·Due: 28 Sep 2026·✓ Verified resolution | Dr. Kwame Asante | Open |
| F-0238 | high | Tracer | MMU.1 (MMU) | Evidence gap identified for MMU.1 during mock surveyor; requires documented remediation. (demonstration) Dept: HR·Due: 18 Aug 2026 | Dr. Carlos Mendez | awaiting-verification |
| F-0239 | medium | 360° Walkthrough | PCI.8 (PCI) | Evidence gap identified for PCI.8 during live field capture; requires documented remediation. (demonstration) Dept: ICU·Due: 27 Sep 2026 | Dr. Kenji Tanaka | awaiting-verification |
| F-0240 | critical | Document intelligence | MMU.6 (MMU) | Evidence gap identified for MMU.6 during document analysis; requires documented remediation. (demonstration) Dept: Laboratory·Due: 18 Aug 2026 | Dr. Kenji Tanaka | awaiting-verification |
| F-0241 | medium | Self-assessment | IPSG.2 (IPSG) | Evidence gap identified for IPSG.2 during self-assessment; requires documented remediation. (demonstration) Dept: Paediatrics·Due: 18 Sep 2026 | Dr. Julian Mercier | Open |
| F-0242 | medium | Staff competency | MMU.7 (MMU) | Evidence gap identified for MMU.7 during learner evaluation; requires documented remediation. (demonstration) Dept: Infection Prevention·Due: 23 Aug 2026 | Dr. Lucas Dubois | Open |
| F-0243 | medium | Tracer | IPSG.2 (IPSG) | Evidence gap identified for IPSG.2 during mock surveyor; requires documented remediation. (demonstration) Dept: Quality·Due: 24 Oct 2026 | Dr. Lucas Dubois | In progress |
| F-0244 | high | 360° Walkthrough | MMU.5 (MMU) | Evidence gap identified for MMU.5 during live field capture; requires documented remediation. (demonstration) Dept: Operating Theatres·Due: 19 Oct 2026 | Dr. Priya Sharma | In progress |
| F-0245 | critical | Document intelligence | QPS.7 (QPS) | Evidence gap identified for QPS.7 during document analysis; requires documented remediation. (demonstration) Dept: Radiology·Due: 18 Aug 2026 | Dr. Ingrid Lindqvist | In progress |
| F-0246 | medium | Self-assessment | QPS.7 (QPS) | Evidence gap identified for QPS.7 during self-assessment; requires documented remediation. (demonstration) Dept: Dialysis·Due: 26 Sep 2026 | Dr. Sofia Rossi | awaiting-verification |
| F-0247 | high | Staff competency | SQE.14 (SQE) | Evidence gap identified for SQE.14 during learner evaluation; requires documented remediation. (demonstration) Dept: Facilities·Due: 27 Oct 2026 | Dr. David Kim | awaiting-verification |
| F-0248 | medium | Tracer | MMU.6 (MMU) | Evidence gap identified for MMU.6 during mock surveyor; requires documented remediation. (demonstration) Dept: Emergency·Due: 28 Oct 2026 | Dr. Elena Rostova | Open |
| F-0249 | medium | 360° Walkthrough | FMS.4 (FMS) | Evidence gap identified for FMS.4 during live field capture; requires documented remediation. (demonstration) Dept: Pharmacy·Due: 25 Sep 2026 | Dr. Sarah Jenkins | awaiting-verification |
| F-0250 | critical | Document intelligence | PCI.5 (PCI) | Evidence gap identified for PCI.5 during document analysis; requires documented remediation. (demonstration) Dept: Maternity·Due: 20 Oct 2026 | Dr. Julian Mercier | Open |
| F-0251 | low | Self-assessment | PCI.7 (PCI) | Evidence gap identified for PCI.7 during self-assessment; requires documented remediation. (demonstration) Dept: Outpatients·Due: 19 Aug 2026·✓ Verified resolution | Dr. Lucas Dubois | Open |
| F-0252 | high | Staff competency | IPSG.1 (IPSG) | Evidence gap identified for IPSG.1 during learner evaluation; requires documented remediation. (demonstration) Dept: HR·Due: 24 Oct 2026·✓ Verified resolution | Dr. Carlos Mendez | Open |
| F-0253 | low | Tracer | MMU.1 (MMU) | Evidence gap identified for MMU.1 during mock surveyor; requires documented remediation. (demonstration) Dept: ICU·Due: 24 Aug 2026 | Dr. Lucas Dubois | Open |
| F-0254 | critical | 360° Walkthrough | PCI.8 (PCI) | Evidence gap identified for PCI.8 during live field capture; requires documented remediation. (demonstration) Dept: Laboratory·Due: 30 Aug 2026 | Dr. Carlos Mendez | In progress |
| F-0255 | medium | Document intelligence | MMU.4 (MMU) | Evidence gap identified for MMU.4 during document analysis; requires documented remediation. (demonstration) Dept: Paediatrics·Due: 19 Oct 2026 | Dr. Elena Rostova | awaiting-verification |
| F-0256 | medium | Self-assessment | FMS.8 (FMS) | Evidence gap identified for FMS.8 during self-assessment; requires documented remediation. (demonstration) Dept: Infection Prevention·Due: 21 Oct 2026·✓ Verified resolution | Dr. Carlos Mendez | awaiting-verification |
| F-0257 | low | Staff competency | PCI.5 (PCI) | Evidence gap identified for PCI.5 during learner evaluation; requires documented remediation. (demonstration) Dept: Quality·Due: 27 Sep 2026 | Dr. Carlos Mendez | In progress |
| F-0258 | low | Tracer | FMS.8 (FMS) | Evidence gap identified for FMS.8 during mock surveyor; requires documented remediation. (demonstration) Dept: Operating Theatres·Due: 23 Sep 2026·✓ Verified resolution | Dr. Lucas Dubois | In progress |
| F-0259 | critical | 360° Walkthrough | IPSG.4 (IPSG) | Evidence gap identified for IPSG.4 during live field capture; requires documented remediation. (demonstration) Dept: Radiology·Due: 25 Oct 2026·✓ Verified resolution | Dr. Sofia Rossi | In progress |
| F-0260 | low | Document intelligence | QPS.7 (QPS) | Evidence gap identified for QPS.7 during document analysis; requires documented remediation. (demonstration) Dept: Dialysis·Due: 25 Oct 2026·✓ Verified resolution | Dr. David Kim | Open |
| F-0261 | medium | Self-assessment | IPSG.6 (IPSG) | Evidence gap identified for IPSG.6 during self-assessment; requires documented remediation. (demonstration) Dept: Facilities·Due: 20 Aug 2026 | Dr. Julian Mercier | Open |
| F-0262 | medium | Staff competency | IPSG.2 (IPSG) | Evidence gap identified for IPSG.2 during learner evaluation; requires documented remediation. (demonstration) Dept: Emergency·Due: 27 Sep 2026·✓ Verified resolution | Dr. Elena Rostova | In progress |
| F-0263 | high | Tracer | SQE.14 (SQE) | Evidence gap identified for SQE.14 during mock surveyor; requires documented remediation. (demonstration) Dept: Pharmacy·Due: 21 Sep 2026·✓ Verified resolution | Dr. Julian Mercier | awaiting-verification |
| F-0264 | high | 360° Walkthrough | FMS.4 (FMS) | Evidence gap identified for FMS.4 during live field capture; requires documented remediation. (demonstration) Dept: Maternity·Due: 25 Aug 2026 | Dr. David Kim | Open |
| F-0265 | critical | Document intelligence | FMS.8 (FMS) | Evidence gap identified for FMS.8 during document analysis; requires documented remediation. (demonstration) Dept: Outpatients·Due: 19 Sep 2026·✓ Verified resolution | Dr. Mateo Hernandez | awaiting-verification |