15.2 Communication to staff occurs Evidence in minutes, agendas, bulletin Staff interview, IA Onsite regarding key ED/UCC risks and document review emerging risks and management strategies 15.3 There is clear ownership of risk Risk register demonstrates risk ownership Document review Onsite IA management through allocation of risk portfolios to ED/UCC staff All incidents and 16.1 ED/UCC incidents, adverse events Review of incident register Incident database Onsite ED near misses are and near misses are recorded in the Review of audits from patient file review for coverage of review reported, incident system all incidents Staff interview, appropriately documentated and 16.2 Management are able to track the Incident reporting such as trends data over 3yr period Report review Onsite ED managed incident trends in the ED/UCC and there is evidence of action taken 16.3 Root casue analysis of serious Sample of highest category incidents have had root cause Report review ED Onsite incidents or adverse events is analysis undertaken undertaken in the ED/UCC 16.4 There is clear articluation of and Open Disclosure Policy/procedure Document review Onsite IA+ED familiarity with the open disclosure Evidence staff familiar with process Staff interview process
15.2 Communication to staff occurs regarding key ED/UCC risks and emerging risks and management strategies Evidence in minutes, agendas, bulletin Staff interview, document review Onsite IA 15.3 There is clear ownership of risk management through allocation of risk portfolios to ED/UCC staff Risk register demonstrates risk ownership Document review Onsite IA All incidents and near misses are reported, appropriately documentated and managed 16.1 ED/UCC incidents, adverse events and near misses are recorded in the incident system Review of incident register Review of audits from patient file review for coverage of all incidents Incident database review Staff interview, Onsite ED 16.2 Management are able to track the incident trends in the ED/UCC and there is evidence of action taken Incident reporting such as trends data over 3yr period Report review Onsite ED 16.3 Root casue analysis of serious incidents or adverse events is undertaken in the ED/UCC Sample of highest category incidents have had root cause analysis undertaken Report review Onsite ED 16.4 There is clear articluation of and familiarity with the open disclosure process Open Disclosure Policy/procedure Evidence staff familiar with process Document review Staff interview Onsite IA+ED
vmia_ecucc_internal_audit_tool_d17-63759.docx