QI No.

: QI/32 Compliance rate of medication prescrip

PSQ3d Total no. of prescription in capital letters/Total n

Year : 2022
Compliance rate of medication prescription in capital
Compliance % of
S.No Month Prescription in Total number of medication prescription
Capital letter prescription
in capital
1 Jan 0 0 #DIV/0!
2 Feb 0 0 #DIV/0!
3 Mar #DIV/0!
4 Apr #DIV/0!
5 May #DIV/0!
6 Jun #DIV/0!
7 Jul #DIV/0!
8 Aug #DIV/0!
9 Sep #DIV/0!
10 Oct #DIV/0!
11 Nov #DIV/0!
12 Dec #DIV/0!
rate of medication prescription in capital

on in capital letters/Total no. of prescriptions*100

% of MR not having ICD

100

80

60

40

20

0
1 2 3 4 5 6 7 8 9 10 11 12
Month
 QI No. : QI/06 Percentage of IN patients developing adve
PSQ 3a Number of patients developing adverse drug reactions/N

Year : 2022
Adverse drug reaction

no. of patients
developing Number of % of Adverse drug
S.No. Month adverse drug inpatients Reactions
Reaction

% of ADR
100

1 Jan 0 890 0 80
2 Feb 0 750 0
60
3 Mar #DIV/0!
4 Apr #DIV/0! 40
5 May #DIV/0!
6 Jun #DIV/0! 20
7 Jul #DIV/0! 0 0 0
8 Aug #DIV/0! 1 2
9 Sep #DIV/0!
10 Oct #DIV/0!
11 Nov #DIV/0!
12 Dec #DIV/0!

Date UHID Details Root Cause CAPA

eveloping adverse drug reaction(s)
erse drug reactions/Number of inpatients*100
Benchmark: XX
% of ADR

100

80

60

40

20

0 0 0
1 2 3 4 5 6 7 8 9 10 11 12
Months
 QI No. : QI/05 Percentage of Medicati
PSQ 3a Total Number of Medication chart with E

Year : 2022
Medication chart with error prone Abbreviations
NUMBER OF PERCENTAGE OF
MONTH MEDICATION CHART NUMBER OF MEDICATION MEDICATION CHART WITH
WITH ERROR PRONE CHART REVIWED ERROR PRONE
ABBREVIATION ABBREVIATION
Jan 0 312 0
Feb 0 171 0
Mar #DIV/0!
Apr #DIV/0!
May #DIV/0!
Jun #DIV/0!
Jul #DIV/0!
Aug #DIV/0!
Sep #DIV/0!
Oct #DIV/0!
Nov #DIV/0!
Dec #DIV/0!

Date UHID Details Root Cause

Root Cause Analysis

Corrective and Preventive action

entage of Medication chart with Error prone Abbreviations
of Medication chart with Error prone Abbreviations /No of Medication Charts Reviewed *100
% of ER abbreviation

Medication chart with error prone Abbreviation

100
90
80
70
60
50
40
30
20
10
0 0 0
1 2 3 4 5 6 Month 7 8 9 10 11

CAPA
ons
eviewed *100

bbreviation

8 9 10 11 12
 QI No. : QI/04 Medication Errors R
PSQ 3a Total No of Medication Errors /Total number of opportu
Monthly

Year : 2022
Rate of Medication

Rate of Me dicati on Error

Medication Total number of Percentage of
S.No Month opportunities of
Error medication errors Medication error

1 Jan 77 3120 2
2 Feb 46 1710 3 Rat
3 Mar #DIV/0! 100
4 Apr #DIV/0!
80
5 May #DIV/0!
6 Jun #DIV/0!
60
7 Jul #DIV/0!
8 Aug #DIV/0!
40
9 Sep #DIV/0!
10 Oct #DIV/0! 20
11 Nov #DIV/0!
12 Dec #DIV/0! 0 2 3
1 2 3
dication Errors Rate
otal number of opportunities of medication errors *100

Benchmark: 3%

Rate of Medication error

100

80

60

40

20

0 2 3
1 2 3 4 5 6Months7 8 9 10 11 12
 QI No. : QI/04 Prescribin
PSQ 3a Total number of Prescription errors / Total nu
Monthly

Year : 2022
Prescribing Error Rate
Total number of Total number of
S.No Month opportunities of
Prescription errors medication errors
1 Jan 6 3120
2 Feb 4 1710
3 Mar
4 Apr
5 May
6 Jun
7 Jul
8 Aug
9 Sep
10 Oct
11 Nov
12 Dec

Date UHID Details Root Cause

06/02/2023 7083165

Error prone
The consultant did
abbreviation were not mention any
used. Dose units were
dose
not mentioned
08/02/2023 7082918

The consultant did

Dose of medication not mention any
were missing. dose

09/02/2023 7081169

Dose of medication The consultant did

were missing. not mention dose.

27/02/2023 7079210

The Doctor did not

mention
Dose of medication
administration
were missing.
instruction in case
sheet
 Prescribing Error Rate
number of Prescription errors / Total number of opportunities of medication errors*100

Benchmark: XX

Rate of Pre scribing Error

Percentage of
Prescription error

0.2
0.2 Rate of Prescribing Error
#DIV/0! 100.0

#DIV/0!
80.0
#DIV/0!
#DIV/0!
60.0
#DIV/0!
#DIV/0!
40.0
#DIV/0!
#DIV/0! 20.0
#DIV/0!
#DIV/0! 0.0 0.2 0.2
1 2 3 4 5 6Months7 8 9 10 11 1

CAPA

Double check
prescription should be
done by physician and
DMo.
DMO should cross verify
the discharge prescription
before transcribing into
discharge summary.
Double check
prescription should be
done by physician and
DMo.
DMO should cross verify
the discharge prescription
before transcribing into
discharge summary.

Double check
prescription should be
done by physician and
DMo.
DMO should cross verify
the discharge prescription
before transcribing into
discharge summary.

Double check
prescription should be
done by physician and
DMo.
DMO should cross verify
the discharge prescription
before transcribing into
discharge summary.
rrors*100

Benchmark: XX

Error

8 9 10 11 12
 QI No. : QI/04 Transcribin
PSQ 3a Total No of Transcription Errors /Total numb
Monthly

Year : 2022
Rate of Transcribing Error
Total number of Total number of
S.No Month opportunities of
Transcription errors medication errors
1 Jan 18 3120
2 Feb 12 1710
3 Mar
4 Apr
5 May
6 Jun
7 Jul
8 Aug
9 Sep
10 Oct
11 Nov
12 Dec

Date UHID Details Root Cause

01/02/2023 626527

Standard protocol was

Initial assessment was not filled
not followed by the DMO

03/02/2023 HMH7081638
Timing of Administration were Standard protocol was
missing in discharge summary not followed by the DMO

04/02/2023 675080

Standard protocol was

Initial assessment was not filled
not followed by the DMO
04/02/2023 HMH7066194

Dose of medication were The consultant did not

missing. mention dose

04/02/2023 679197

Standard protocol was

Initial assessment was not filled
not followed by the DMO

05/02/2023 673306

Timing of Administration were Standard protocol was

missing in discharge summary not followed by the DMO

07/02/2023 HMH7081629

Dose of medication were The consultant did not

missing. mention dose

07/02/2023 HMH7083171

Administration instructions
The consultant did not
were not mentioned in discharge
mention dose
summary

22/02/2023 HMH7085412

Standard protocol was

Initial assessment was not filled
not followed by the DMO

22/02/2023 647004

Dose of medication were The consultant did not

missing. mention dose

22/02/2023 HMH7053184

Administration instructions
Standard protocol was
were not mentioned in discharge
not followed by the DMO
summary
24/02/2023 480419

In discharge summary,Atrax
The consultant did not
was prescribed without
mention dose
discharge instruction
 Transcribing Errors Rate
No of Transcription Errors /Total number of opportunities of medication errors *100

Benchmark: XX

Rat e of Transcripti on Error

Percentage of
Transcription error

1
1
#DIV/0!
Rate of Transcribing error
100
#DIV/0!
#DIV/0! 80
#DIV/0!
#DIV/0! 60

#DIV/0!
40
#DIV/0!
#DIV/0!
20
#DIV/0!
#DIV/0! 0 1 1
1 2 3 4 5 6Months7 8 9 10 11 12

CAPA
Standard protocol should
be documented followed

Daily audit
Standard and Prompt
protocol should
Correction
be documented followed

Daily audit and Prompt

Correction

Standard protocol should

be documented followed

Daily audit and Prompt

Correction
Standard protocol should
be documented followed

Daily audit and Prompt

Correction

Standard protocol should

be documented followed

Daily audit and Prompt

Correction

Standard protocol should

be documented followed

Daily audit and Prompt

Correction

Standard protocol should

be documented followed

Daily audit and Prompt

Correction

Standard protocol should

be documented followed

Daily audit and Prompt

Correction

Standard protocol should

be documented followed

Daily audit and Prompt

Correction

Standard protocol should

be documented followed

Daily audit and Prompt

Correction

Standard protocol should

be documented followed

Daily audit and Prompt

Correction
Standard protocol should
be documented followed

Daily audit and Prompt

Correction
enchmark: XX

9 10 11 12
 QI No. : QI/04 Administration
Total No of Errors Rate
Administration
PSQ 3a Errors /Total number
of opportunities of
Monthly medication errors *100

Year : 2022
Rate of Administration Errors
Total number of Total number of
S.No Month opportunities of
Administration errors medication errors
1 Jan 24 3120
2 Feb 16 1710
3 Mar
4 Apr
5 May
6 Jun
7 Jul
8 Aug
9 Sep
10 Oct
11 Nov
12 Dec

Date UHID Details Root Cause

01/02/2023 7082387 high risk medication was not The Nurse did not sign
double signed drug chart

01/02/2023 7072000 Medication administration was The Nurse did not sign
not documented drug chart
02/02/2023 7082477 admintration documentation were The Nurse did not sign
missing in drug chart drug chart

03/02/2023 7023074 Medication administration was The Nurse did not sign
not documented drug chart

03/02/2023 7082689 Medication administration was The Nurse did not sign
not documented drug chart

04/02/2023 499135 admintration documentation were The Nurse did not sign
missing in drug chart drug chart

04/02/2023 7062586 admintration documentation were The Nurse did not sign
missing in drug chart drug chart
05/02/2023 7082941 Medication administration was The Nurse did not sign
not documented drug chart

05/02/2023 7082936 Medication administration was The Nurse did not sign
not documented drug chart

07/02/2023 7080648 admintration documentation were The Nurse did not sign
missing in drug chart drug chart

07/02/2023 7053943 Medication administration was The Nurse did not sign
not documented drug chart

07/02/2023 7083269 admintration documentation were The Nurse did not sign
missing in drug chart drug chart
22/02/2023 7082507 admintration documentation were The Nurse did not sign
missing in drug chart drug chart

23/02/2023 7085651 Medication administration was The Nurse did not sign
not documented drug chart

24/02/2023 656999 admintration documentation were The Nurse did not sign
missing in drug chart drug chart

24/02/2023 467122 Medication administration was The Nurse did not sign
not documented drug chart
 Benchmark: XX

R at e o f A d m in ist rati o n Er r o r s

Percentage of
Administration error

1
1
#DIV/0! Rate of Administration Errors
#DIV/0! 100

#DIV/0!
80
#DIV/0!
#DIV/0! 60
#DIV/0!
#DIV/0! 40

#DIV/0!
20
#DIV/0!
#DIV/0! 0 1 1
1 2 3 4 5 6Months7 8 9 10 11 12

Medication related
handover policy should be
adhered
Communication between
nurses
CAPAtraining should be
given
Daily audit and Prompt
Correction by ward
incharge

Medication related
handover policy should be
adhered
Communication between
nurses training should be
given
Daily audit and Prompt
Correction by ward
incharge
Medication related
handover policy should be
adhered
Communication between
nurses training should be
given
Daily audit and Prompt
Correction by ward
incharge

Medication related
handover policy should be
adhered
Communication between
nurses training should be
given
Daily audit and Prompt
Correction by ward
incharge

Medication related
handover policy should be
adhered
Communication between
nurses training should be
given
Medication related
Daily audit and Prompt
handover
Correctionpolicy should be
by ward
adhered
incharge
Communication between
nurses training should be
given
Daily audit and Prompt
Correction by ward
incharge

Medication related
handover policy should be
adhered
Communication between
nurses training should be
given
Daily audit and Prompt
Correction by ward
incharge
Medication related
handover policy should be
adhered
Communication between
nurses training should be
given
Daily audit and Prompt
Correction by ward
incharge

Medication related
handover policy should be
adhered
Communication between
nurses training should be
given
Daily audit and Prompt
Correction by ward
incharge

Medication related
handover policy should be
adhered
Communication between
nurses training should be
given
Daily audit and Prompt
Correction by ward
incharge

Medication related
handover policy should be
adhered
Communication between
nurses training should be
given
Daily audit and Prompt
Correction by ward
incharge

Medication related
handover policy should be
adhered
Communication between
nurses training should be
given
Daily audit and Prompt
Correction by ward
incharge
Medication related
handover policy should be
adhered
Communication between
nurses training should be
given
Daily audit and Prompt
Correction by ward
incharge

Medication related
handover policy should be
adhered
Communication between
nurses training should be
given
Daily audit and Prompt
Correction by ward
incharge

Medication related
handover policy should be
adhered
Communication between
nurses training should be
given
Daily audit and Prompt
Correction by ward
incharge

Medication related
handover policy should be
adhered
Communication between
nurses training should be
given
Daily audit and Prompt
Correction by ward
incharge
rs

9 10 11 12
 QI No. : QI/04 Dispensing E
PSQ 3a Total No of Dispensing Errors /Total number o
Monthly

Year : 2022
Rate of Dispensing Error
Total number of Total number of Percentage of
S.No Month opportunities of
Dispensing errors medication errors Dispensing error

1 Jan 0 3120 0
2 Feb 0 1710 0
3 Mar #DIV/0!
4 Apr #DIV/0!
5 May #DIV/0!
6 Jun #DIV/0!
7 Jul #DIV/0!
8 Aug #DIV/0!
9 Sep #DIV/0!
10 Oct #DIV/0!
11 Nov #DIV/0!
12 Dec #DIV/0!

Date UHID Details Root Cause CAPA

 Dispensing Errors Rate
g Errors /Total number of opportunities of medication errors *100

Benchmark: XX
Rate of Dispensing Error

Rate of Dispensing error

100

80

60

40

20

0 0 0
1 2 3 4 5 6Months7 8 9 10 11 12
 QI No. : QI/04 Documentati
PSQ 3a Total No of Documentation Errors /Total nu
Monthly

Year : 2022
Rate of Documentation Error
Total number of Total number of
S.No Month opportunities of
Documentation errors medication errors
1 Jan 29 3120
2 Feb 14 1710
3 Mar
4 Apr
5 May
6 Jun
7 Jul
8 Aug
9 Sep
10 Oct
11 Nov
12 Dec

Date UHID Details Root Cause

01/02/2023 560281 Weight were not documented. Increased no of patient
cover

02/02/2023 7012894 Dose were missing in Past Standard protocol was

medication History not followed by the DMO

03/02/2023 7077421 Past mediction history was not Standard protocol was
documented (Frequency and not followed by the DMO
ROA)
03/02/2023 7082709 Height and weight were not Increased no of patient
documented. cover

03/02/2023 7082723 ROA was missing in the drug Standard protocol was
chart not followed by the DMO
03/02/2023 7082630 Height and weight were not Increased no of patient
documented. cover

03/02/2023 7082565 Height and weight were not Increased no of patient

documented cover

03/02/2023 557062 Height and weight were not Increased no of patient

documented. cover

04/02/2023 7082878 Height and weight were not Increased no of patient

documented. cover
Dose of medication were missing.

04/02/2023 473589 Weight were not documented. Standard protocol was

not followed by the DMO

07/02/2023 7083311 Height and weight were not Increased no of patient

documented. cover

22/02/2023 7085515 Error prone abbreviation were Standard protocol was

used. Dose units were not not followed by the DMO
mentioned
22/02/2023 397840 In discharge summary, Pan was Standard protocol was
prescribed without dose not followed by the DMO

23/02/2023 7073616 Height and weight were not Increased no of patient

documented. cover

25/02/2023 7023700 Paitent was known case of DM, Standard protocol was
CvD Medication reconcillation not followed by the DMO
was not filled
25/02/2023 7085810 Paitent was known case of HTN Standard protocol was
Medication reconcillation was not not followed by the DMO
filled
 Documentation Errors Rate
of Documentation Errors /Total number of opportunities of medication errors *100

Benchmark: XX
Rate o f Do cu m e ntati on Error

Percentage of
Documentation
error
1
1
#DIV/0! Rate of Documentation error
100
#DIV/0!
#DIV/0! 80
#DIV/0!
#DIV/0! 60
#DIV/0!
#DIV/0! 40
#DIV/0!
#DIV/0! 20
#DIV/0!
0 1 1 Months
1 2 3 4 5 6 7 8 9 10 11 12

CAPA
Daily audit and
Prompt Correction by
ward incharge
Daily audit and
Prompt Correction by
ward incharge
Daily audit and
Prompt Correction by
ward incharge
Daily audit and
Prompt Correction by
ward incharge
Daily audit and
Prompt Correction by
ward incharge
Daily audit and
Prompt Correction by
ward incharge
Daily audit and
Prompt Correction by
ward incharge
Daily audit and
Prompt Correction by
ward incharge

Daily audit and

Prompt Correction by
ward incharge
Daily audit and
Prompt Correction by
ward incharge
Daily audit and
Prompt Correction by
ward incharge
Daily audit and
Prompt Correction by
ward incharge
Daily audit and
Prompt Correction by
ward incharge
Daily audit and
Prompt Correction by
ward incharge
Daily audit and
Prompt Correction by
ward incharge
Daily audit and
Prompt Correction by
ward incharge
0

enchmark: XX

or

9 10 11 12