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Lessons to learn
Ensure that all staff
o
Are properly trained in safety critical procedures
o
Are included in training programmes and has supervision as necessary,
and that records of training are kept up-to-date
o
Understand their responsibilities
Include in the Quality Assurance Program
o
Formal procedures for verifying the risks following the introduction of
new technologies and procedures
o
Independent MU checking of ALL treatment plans
Review staffing levels and competencies
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2016-10-05
T Knöös