Clinical Audit

Quality indicators, audit cycle tracking, and corrective actions

Active Audits

2

Action Pending

1

Completed (2026)

8

Avg Compliance

75%

Antibiotic Prescribing Compliance (Surgical Prophylaxis)

Completed
Surgery / PharmacyApr–May 2026Lead: Dr. S. Mehta

21/28 cases received correct antibiotic; 7 exceeded recommended duration. AMS policy non-compliance in 25% of elective cases.

74% (target 90%)

VTE Prophylaxis in IPD Patients > 24h

In Progress
Medicine / Surgery / OrthopedicsJun 2026Lead: Dr. R. Iyer

Interim data: risk assessment done in 61% of eligible admissions. Enoxaparin prescribed in 58%.

61% (target 95%)

Informed Consent Documentation (OT)

Action Pending
OT / LegalMay 2026Lead: Mr. A. Patel

18% of consent forms missing procedure-specific risks documented. NABH non-compliance — immediate action required. SOP updated.

82% (target 100%)

Hand Hygiene Compliance — 5 Moments Audit

In Progress
Infection Control / NursingJun 2026Lead: IC Nurse

Overall compliance 91%. Below target only in Moment 5 (after patient environment contact) — 88%.

91% (target 90%)

Discharge Summary Completion within 24h

Completed
Medical RecordsMay 2026Lead: MRD Head

68% summaries completed within 24h of discharge. 32% delayed. Root cause: junior residents on night shifts not completing summaries.

68% (target 95%)