F-0142
critical
Open
Chapter MMUIndependent double-check for high-alert medications not consistently performed at administration; self-assessment claimed 94% but evidence supports 71% and observed practice 68%.
Department: Pharmacy•Accountable Owner: Dr. Fatima Al-Mansoor•Identified via: Mock surveyor
86%Accredisense Intelligence Confidence
Explainability & Evidence Trace
Standard Alignment:
This non-compliance was flagged after cross-referencing floor inspection logs with current hospital medication administration records.
Update policy with defined threshold
identified
Effort: 8 d · Dept: Pharmacy
Owner: Dr. Ingrid LindqvistDue Date: 21 Sep 2026