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Internal audit exposes practice in urgency codes

In the first half of 2023, an internal audit was carried out on the “urgency codes” protocol. Changes to the protocol were the reason. Adjustments were made based on the results of various calamity and incident investigations. We have already brought the new protocol to your attention several times. The internal audit makes it clear how this protocol is implemented in practice. The following conclusions were drawn:

  1. Information i’s are not always used by triage nurses. Since this changes every now and then, this is also important for experienced triage nurses to read.
  2. It is unclear whether all directing physicians are aware of the information.
  3. The protocol states that a maximum of 1 urgency may be scaled down. Some employees scale down 2 urgencies.
  4. The protocol states that scaling down is only allowed in consultation with the directing physician. Some employees think that scaling down 1 urgency is allowed without consultation.
  5. After completing the triage, the urgency can also be changed, but then the system no longer asks for a reason for change. Noting why it is being scaled up or down remains important.
  6. Not all agents note when a contact is scaled up or down.
  7. There are no working agreements on where the argumentation (for scaling down or scaling up the urgency) will be noted.
  8. Difference in method of visits. At the Leiderdorp location, all visits are discussed with the directing doctor. At the Voorhout location, not all visits are discussed with the directing physician.

Results of an internal audit are always discussed with a few members of the management team. In these consultations, it is determined for which findings improvement measures will be developed.  

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