Signature of Authorised signatory. Signature of Authorised signatory OR WHERE PROVIDER IS AN INCORPORATED COMPANY Executed as a deed by the Provider ) acting by [insert name of Director], ) …………………………………………………... a director, in the presence of: ) Director Witness Signature: ……………………………………… Name: ……………………………………… Address: ……………………………………… Occupation: ……………………………………… OR WHERE PROVIDER IS A LIMITED LIABILITY PARTNERSHIP Executed as a deed by the Provider ) acting by [insert name of Member], ) Member and [insert name of ) Member], Member ) …………………………………………………... Signature of Member …………………………………………………... Signature of Member OR Executed as a deed by the Provider ) acting by [insert name of Member], ) …………………………………………………... a Member, in the presence of: ) Member Witness Signature: ……………………………………… Name: ……………………………………… Address: ……………………………………… Occupation: ……………………………………… APPENDIX 1 Section 3 Part 2 of Module B: Never Events Never Events Threshold Method of Measurement Never Event Consequence (per occurrence) Wrongly prepared high-risk injectable medication >0 Review of reports submitted to National Patient Safety Agency (or successor body)/Serious Incidents reports and monthly Service Quality Performance Report In accordance with applicable Guidance, recovery of the cost of the procedure and no charge to Commissioner for any corrective procedure or care Maladministration of potassium-containing solutions >0 Review of reports submitted to National Patient Safety Agency (or successor body)/Serious Incidents reports and monthly Service Quality Performance Report In accordance with applicable Guidance, recovery of the cost of the procedure and no charge to Commissioner for any corrective procedure or care Wrong route administration of oral/enteral treatment >0 Review of reports submitted to National Patient Safety Agency (or successor body)/Serious Incidents reports and monthly Service Quality Performance Report In accordance with applicable Guidance, recovery of the cost of the procedure and no charge to Commissioner for any corrective procedure or care Intravenous administration of epidural medication >0 Review of reports submitted to National Patient Safety Agency (or successor body)/Serious Incidents reports and monthly Service Quality Performance Report In accordance with applicable Guidance, recovery of the cost of the procedure and no charge to Commissioner for any corrective procedure or care Maladministration of Insulin >0 Review of reports submitted to National Patient Safety Agency (or succes...
Signature of Authorised signatory. Executed as a deed by affixing the common seal of the PROVIDER in the presence of: [COMMON SEAL] .................................................
Signature of Authorised signatory. Executed as a deed by [DEVELOPER] acting by [ ], in the presence of: Witness sign Witness Name Witness Address Witness occupation ....................................... SIGNATURE OF [ ] Legal02#82105323v1[MZC1]
Signature of Authorised signatory. [Please delete as appropriate – mechanism for execution will be subject to the Authority’s constitution and Scheme of Delegation] SIGNED by [Insert Authorised Signatory’s Name] for and on behalf of the PROVIDER ………………………………………………………….. Signature ………………………………………………………….. Title ………………………………………………………….. Date
