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         Indicator Data (clinical & managerial)

All indicators as per the Standards like


medication errors, near miss, sentinel
events, patient satisfaction, employee
satisfaction, etc. with discussion and root
cause analysis.

Department-wise QIPs to be submitted with


targets and performance in the past year.
Evidence of validation of data methodology

List of Indicators

Methodo
Indicato logy &
Sl. sample
rs
size

Time for
initial
assessm
ent of
9.1. indoor
and
emergen
cy
patients.

Number
of
reporting
errors/10
00
9.2.
investiga
tions.(lab
&
diagnosti
c)
Percenta
ge of
adherenc
e to
safety
precautio
9.3. ns by
employe
es
working
in
diagnosti
cs.

Incidenc
e of
9.4. medicati
on
errors.

Incidenc
e
9.5.
Prescripti
on error

Incidenc
e
9.6.
Dispensi
ng error

Percenta
ge of
patients
receiving
high-risk
medicati
9.7.
ons
developi
ng
adverse
drug
event.

Percenta
ge of
adverse
9.8.
anaesthe
sia
events.
Anaesth
esia-
9.9. related
mortality
rate.

Percenta
ge of
cases
where
the
organisat
ion’s
procedur
e to
prevent
adverse
events
9.10. like
wrong

site,
wrong
patient
and
wrong
surgery
have
been
adhered
to.

Percenta
ge of
cases
who
received
appropri
ate
9.11. prophyla
ctic
antibiotic
s within
the
specified
time
frame.
Percenta
ge of
transfusi
9.12.
on
reactions
.

Catheter
Associat
ed
9.13. Urinary
Tract
Infection
rate.

Ventilato
r
Associat
9.14.
ed
Pneumo
nia rate.

Central
line
associat
ed
9.15.
bloodstre
am
infection
rate.

Surgical
site
9.16.
infection
rate.
Mortality
9.17.
rate.
Return to
ICU
9.18.
within 48
hours.
Return to
the
emergen
cy
departm
ent
within 72
9.19.
hours
with
similar
presentin
g
complain
ts.

Re-
9.20. intubatio
n rate.

Incidenc
e of
Commun
ication
9.21.
errors
including
handover
s

Incidenc
e of
Patient
9.22.
identifica
tion
errors

Complia
nce to
9.23. Hand
hygiene
practice

Percenta
ge of
stock
9.24. outs
including
emergen
cy drugs.
Incidenc
9.25.
e of falls.

Incidenc
e of
hospital
associat
ed
9.26.
pressure
ulcer
after
admissio
n.

Percenta
ge of
staff
provided
9.27. pre-
exposure

prophyla
xis.
Bed
occupan
cy rate
9.28. and
average
length of
stay.

Critical
equipme
9.29.
nt down
time.

Nurse-
patient
9.30. ratio for
ICUs and
wards.

Out-
patient
9.31.
satisfacti
on index.
In-patient
9.32. satisfacti
on index.

Percenta
ge of
sentinel
events
reported,
collected
9.33. and
analysed
within
the
defined
time
frame.

Percenta
ge of
9.34.
near
misses.

Incidenc
e of
blood
9.35. body
fluid
exposure
s.

Incidenc
e of
9.36. needle
stick
injuries.
Percenta
ge of
9.37.
missing
records.

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