Clinical Audit
Audit register, evidence-based standards, gap analysis, and re-audit tracking
Key Audit Indicators vs Target
Surgical Safety Checklist (SSC) Compliance — AUD-2026-012
Lead: Dr. K. Kumar (Surgery) · Standard: WHO SSC — target 100%
Result: 88% compliance (audit of 50 consecutive cases)
Gap: 12% — 'Sign-out' step most frequently missed
Action: Mandatory re-training. SSC compliance added to OT KPIs. Re-audit in 3 months.
Antibiotic Prophylaxis — Surgical (SCIP measure) — AUD-2026-011
Lead: Dr. M. Raj (Anaesthesia) · Standard: Prophylaxis within 60 min pre-incision, correct antibiotic, discontinued ≤ 24h
Result: 93% within 60 min. 12% exceeded 24h duration.
Gap: Post-op duration compliance — nurses not stopping after 24h
Action: Automated order stop in EPR. Pharmacy alert at 24h.
VTE Prophylaxis Documentation — AUD-2026-010
Lead: Dr. A. Nair (Medicine) · Standard: VTE risk assessment documented within 24h of admission — target 95%
Result: 72% documented within 24h
Gap: Medical admissions worst (65%). Prophylaxis not prescribed in 28% of high-risk.
Action: VTE prompt added to admission clerking proforma. Pharmacist review daily.