DEPARTMENT

EMERGENCY

Time for initial assessment

Return to emergency within 72 hours with similar presenting complaints hand hygiene compliance
Compliance to medication prescription in capitals
Medication error rates
Number of variations in mock drills (disaster management)
OPD
Compliance rate to medication prescription in capitals
Waiting time for outpatient consultation
WARDS - IP - NURSING

time for initial assessment

medication error rates
percentage of medication charts with error prone abbreviations percentage of patients developing ADRs
percentage of cases - prevent adverse events like a wrong site, patient, surgery
percentage of transfusion reactions
incidence of hospital associated pressure ulcers after admission
cauti
ssi
CLABSI
Hand hygiene compliance rate
nurse patient ratio
incidence of niddle stick injury
appropriate hand over during shift change
compliance rate to medication prescription in capitals
patient fall rate
percentage of near-misses
DAYCARE
incidence of needle stick injury
OPERATION THEATRE
medication error rates
percentage of medication charts with error prone abbreviations
percentage of patients developing ADRs
percentage of unplanned return to OT
percentage of cases - prevent adverse events like a wrong site, patient, surgery
percentage of transfusion reaction
SSI
HAND hygiene COMPLIANCE rate
compliance rate
percentage of cases who received appropriate prophylactic antibiotic within the specified time frame
percentage of rescheduling of surgeries
nurse patient ratio
incidence of niddle stick injury
appropriate hand over during shift change
compliance rate to medication prescription in capitals
percentage of medical record having incomplete and or improper consent patient fall rate
percentage of near misses
RADIOLOGY
number of reporting error
Percentage of adherence to safety precautions by staff working in diagnostics

waiting time for diagnostic

LAB
number of reporting error
percentage of safety precautions by staff working in diagnostics
waiting time for diagnostic
HOSPITAL INFECTION CONTROL
Cauti
clabsi
ssi
hand hygiene compliance rate
Nurse patient ratio
incidence of needle stick injury.
MEDICAL RECORDS
records not having discharge summary
records not ICD codified
records with incomplete consents
percentage of missing records
FRONT OFFICE
waiting time for OP consultation
PHARMACY
percentage of drugs or consumables procured by local purchase
percentage of stockouts
percentage of drugs or consumables rejected before GRN
percentage of variations from procurement process
8/1/2022 8/2/2022 8/3/2022 8/4/2022 8/5/2022 8/6/2022 8/7/2022 8/8/2022 8/9/2022 8/10/2022

10minute
s 8minutes 8minutes 10minutes 6minutes 8minutes 8minutes 10min 5min 10min
0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 0

8min 6min 10min 10min 8min 5min 9min 10min 10min 10min
a 25 min 15 min 15 min 20 min 20 min 25 min 25 min 25 min 20min

20minute 15minute 20minute

s s s 15 min 15min 25min 20min 10min 20min 18min
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0 0
yes yes yes yes yes yes yes yes yes yes

0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
 0% 0% 0% 0%
100% 100% 100% 100%
10 10
minutes minutes

0 0 0 0 0 0 0 0 0 0
100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
10 Mints 10 Mints 05 Mints 10 Mints 06 Mints 2 Mints 4 mints 5mints 5 Mints 6 Mints

0 0 0 0 0 0 0 0 0 0
NA NA NA NA NA NA NA NA NA NA
NA NA NA NA NA NA NA NA NA NA
0 0 0 0 0 0 0 0 0 0

20 mits 25 mits 15 mits 15 mits 20 mits 20 mits 25 mits 25 mits 25 mits 10 mits

0% 0 0 0 0 0 0 0
8% 10 15 10 12 15 12 10
0% 0 0 0 0 0 0 0
0% 0 0 0 0 0 0 0
8/11/2022 8/12/2022 8/13/2022 8/14/2022 8/15/2022 8/16/2022 8/17/2022 8/18/2022 8/19/2022 8/20/2022

10min 7min 9min 8min 10min 10min 5min 8min 10min 6min
0 0 0

0 0 0
0 0 0

8min 6min 10min

18min 15min 20min

25min 15min 20min 20min 15min 25min 15min 10min 16min 18min
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0

0 0 0 0 0 0 0 0 0
yes yes yes

0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0
 0 0 0 0 0 0 0 0 0 0
100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
2 Mints 10 Mints 10 Mints 05 Mints 10 Mints 06 Mints 2 Mints 4 mints 5mints 05 Mints

0 0 0 0 0 0 0 0 0 0
NA NA NA NA NA NA NA NA NA NA
NA NA NA NA NA NA NA NA NA NA
0 0 0 0 0 0 0 0 0 0

25 mits 20 mits 25 mits 15 mits 20 mits 25 mits 10 mits 20 mits 20 mits 15 mits
8/21/2022 8/22/2022 8/23/2022 8/24/2022 8/25/2022 8/26/2022 8/27/2022 8/28/2022 8/29/2022 8/30/2022
 0 0 0 0 0 0 0 0 0
100% 100% 100% 100% 100% 100% 100% 100% 100%
02 Mints 08 Mints 6 mints 8 Mints 6 Mints 2 mints 04 Mints 02 Mints 6

15 mits 20 mits 25 mits 10 mits 20 mits 20 mits 20 mits 20 mits

8/31/2022