Quality / Clinical Audit - V1-27/09/2023

IPSG 1 Patient band available on the patient wrist (Limb for newborn babies)

IPSG 1 Patient identification appropriate (Lab & radiology requisitions, Drugs labelling & Storing etc.)

IPSG 1 Patient labelling on all Medications

IPSG 2 Write Down Read-back and Confirm logs (Completeness)

IPSG 2 Date & Time of order

IPSG 2 ID# of Employee with notes in EHR / Logs

IPSG 2 Completeness of orders (In case of drug orders)

IPSG 2 Order sorted and completed within 24 hours

IPSG 2.1 Staff aware of critical results. Critical results are documented in the Write down, Read-back and Confirm logs

IPSG 2.2 Patient handover during transfer to other department documented in SBAR

IPSG 3 High-alert medications identified with red sticker

IPSG 3 High-alert medication stored in area with access cards or locked cupboards

IPSG 3 High-alert medication checklist is updated and monthly signed by the pharmacist

IPSG 4 Safe Surgery

Time Out

Sign In

Site Marking

IPSG 3 LASA drugs are stored with appropriate label

IPSG 6 Patient calls bells are in working condition

IPSG 6 Bed side rails are up

IPSG 6 Wheelchair and Stretcher straps are available

IPSG 6 Patients at high risk for fall identified with red band

MMU RTF labeled and stored appropriately (Dedicated place with temperature monitoring)

MMU Contrast labeled and stored appropriately

MMU 3 Medication Trolley - locked

MMU 3 Left over medications post discharge sent to pharmacy

MMU 3 Opened medication vails/tubes identified with opening/expiry date

MMU 3 LASA seperated by a drug barrier and has label

MMU 3 Drugs are not expired (in patient trolley, buffer stock & crash cart)

Narcotics key with 2 different staffs

MMU 3 Narcotics physical quantity matches with the stock register

MMU 3 Narcotics are not expired

MMU 3.1 Patient own medication (not continued) stored seperately

MMU 3.2 Crash cart locked

MMU 3.2 Crash cart checked - tab daily

MMU 3.2 Crash cart checked - monthly check by pharmacist

MMU 3.2 Buffer stock (if available), stock checking done

MMU 3.2 Buffer stock physical qty matching with the register

MMU 4 Patients own medication labeled and kept pat own medicine drawer

MMU 5.2 Prefilled medications/syringes labeled with drug, date & time of preparation

MMU 6 IV medications on flow - labeled with Name of the drug, time & date started, sign of the person starting

MMU 3 Temperature of medicine fridge checked

MMU 3 Only medications stored in fridge

FMS 8 Fridge PPM done

FMS 8 Temperature Monitor Alarm not kept in Off mode

MMU 3 Medicine fridge kept locked

FMS 8 Daily defibrillator check done

FMS 8 Defibrillator check passed

FMS 8 Staff demonstrate the defib check done in battery mode (power switch off)

PPM sticker on equipment is current.

Crash cart closed within 3 hours

AOP 5.9 Glucometer QC Form updated and signed by lab / <br>For CSSD - Bowie dick<br>Biological indicator is using to ensure the efficacy

AOP 5.9 QC if failed, concerned supervisor informed and action taken

Lead apron stored appropriately

Lead apron PPM not expired

MOI.2 The hospital has a written process that protects the confidentiality, security, and integrity of data and information.

MOI.3 Release of Medical records are done as per the protocol

MOI.3 Records, data, and information are destroyed in a manner that does not compromise confidentiality and security.

MOI.6 Records and information are protected from loss.

MOI.7 Records and information are protected from damage or destruction.

MOI.8.1 Staff awarness on departmental policies

MOI.12 Medical Record audit are conducted

Staff Aware about the use of Shared Data

Aware of Departmental KPI (QI Plans in place if any. etc.)

Awareness on Occurrence Variance Reporting (How to report, what's it for, awareness of blame free culture etc.)

Awareness about sentinel Event