CLINICAL INDICATOR

ANALYSIS
UHKDU
PROCEDURE FOR CLINICAL ANALYSIS
SOP-C&R-01 Internal Processes for Data Collection and Analysis .pdf
TRAINING ON CLINICAL INDICATORS
QUALITY INDICATOR TRAINING.pdf
 CLINICAL DATA ANALYSIS
All wards

S.No Clinical Indicator Description Neumerators Denominators Ratio Responsibility

All Wards

Number of Needle prick Injuries (NSI) Number of Needle prick Injuries (NSI)
1 Number of Needle prick Injuries (NSI) reported in a month Number of patient Admissions No of NSI MOIC, Incharge Sister , MA
reported in a month reported in a month

Patient Identification Ratio Patient identification compliance for critical data No of Patient Identification Errors x1000
2 Number of wrong Patient Identifications No of Patient Admittions Per month MOIC, Incharge Sister , MA
(Identify patients correctly ) per 1000 patient admissions No of Patient Admitions Per month

Communication Error Rate No of Communication Errors reported x1000

3 Communication Compliance for 1000 patient admissions Number of Communication errors reported No of Patient Admittions Per month MOIC, Incharge Sister , MA
(Improve Effective Communication) No of Patient Admitions Per month

Reduce the risk of patient harm resulting from falls

assess with completion of Fall Assessment.calculation No of reported patient falls per month X 100
4 Patient Falls Rate No of reported Patient Falls per month No of Patient Admittions Per month MOIC, Incharge Sister , MA
based on per month admissions and no of reported patient No of Patient admissions per month
falls.

No of Patients developed ADR's X 1000 Patients

5 Average Drug reaction Rate Average Drug reaction Rate for 1000 patients No of patients developed ADR's Total Admission Per Month MOIC, Incharge Sister , MA
Total Admission Per Month
NEEDLE STICK INJURIES- ALL WARDS
1.00
0.90
0.80
0.70
0.60
0.50 Number of Needle prick Injuries
(NSI)
0.40
0.30
0.20
0.10
0.00
December January February

December January February

Number of Needle Stick Injuries (NSI)
1 1 1
reported in a month
Number of Patient Admissions 4490 4390 4430
Number of Needle Stick Injuries (NSI) 0.22 0.02 0.023
Hospital Target 0 0 0
CORRECT PATIENT IDENTIFICATION RATIO
(IDENTIFY PATIENTS CORRECTLY )
100%

90%

80%

70%

60%

50%
Patient Identification Ratio
40%

30%

20%

10%

0%
December January February

December January February

No of Patient Identification Errors 4490 4390 4430

No of Patient Admissions Per month 4490 4390 4430

Patient Identification Ratio 100% 100% 100%

Hospital Target 100% 100% 100%

COMMUNICATION ERROR RATE

0.95
0.85
0.75
0.65
0.55
0.45
0.35
0.25
0.15
0.05
December January February
Series1 0 0 0

December January February

No of Communication Errors 0 0 0
No of Patient Admitions Per month 4490 4390 4430
Communication Error Rate 0 0 0
Hospital Target 0 0 0
PATIENT FALL RATE
0.95
0.85
0.75
0.65
0.55
Patient Fall Rate

0.45
0.35
0.25
0.15
0.05
December January February
Series1 0.400801603206413 0.227790432801822 0.225733634311512

December January February

No of reported patient falls per month 2 1 1
No of Patient admissions per month 4990 4390 4430
Patient Fall Rate 0.400802 0.2277904 0.2257336
Hospital Target 0 0 0

Actions to Achieve target

• Patient Fall Risk assess in nursing assessment and Daily pain fall skin assessment forms.
• Safety signs are pasted in all wards and wash room areas.
• Patient will be informed during admission for safety precautions.
• Continue Hospital Incident reporting procedure for further actions.
 AVERAGE DRUG REACTION RATE

0.9

0.8

0.7

0.6 No of Patients developed

ADR's
0.5

0.4

0.3

0.2

0.1

0
December January February

December January February

No of Patients developed ADR's 0 0 0
Total Admission Per Month 4990 4390 4430
Average Drug reaction Rate 0 0 0
Hospital Target 0 0 0
PATIENT SATISFACTION RATE
95
85
75
Patient Satisfaction Rate

65
55
45
35
25
15
5
December January February
Patient Satisfac- 98.3333333333333 99.1428571428571 99.3333333333333
tion rate

December January February

Patient Satisfaction rate 98 99 99

Hospital Target > 95 > 95 > 95

CLINICAL INDICATORS- INFECTION CONTROL
Surgical Site Infection ( SSI)

0.95
0.85
0.75
Compliance Rate

0.65
0.55
0.45
0.35
0.25
0.15
0.05
December January
SSI 0 0

December January
No. of SSI’s 0 0
No. of Surgical Sites 19 59
SSI 0 0
Hospital Target 0 0
CLINICAL INDICATORS- INFECTION CONTROL
Catheter Site Infection Reported

0.95
Compliance Rate 1000 Catheter Days 0.85
0.75
0.65
0.55
0.45
0.35
0.25
0.15
0.05
December January
CAUTI for 1000 catheter days 0 0

Month December January

No of Catheter Site Infection reported 0 0
No of catheter days recorded 53 3
CAUTI for 1000 catheter days 0 0
Hospital Target 0 0
CLINICAL INDICATORS- INFECTION CONTROL
Cannula site infection for 1000 cannula days
0.95
0.85
0.75
0.65

Compliance Rate
0.55
0.45
0.35
0.25
0.15
0.05
December January
Cannula site Infection for 1000 cannular days 0 0

Moths December January

No of Cannula Site Infection reported 0 0
No of cannula days recorded 112 867
Cannula site Infection for 1000 cannular days 0 0
Hospital Target 0 0
 CLINICAL INDICATOR – LABORATORY
S.No Clinical Indicator
All Lab sections
Number of Needle prick
1 Injuries (NSI)
reported in a month
Samples That Could Not Be
2 Processed Due to Incorrect
Patient Information/Vial
Samples That Could Not Be samples discarded due to Number of samples
3 Analyzed Due to an Incorrect incorrect collection
Collection
4 Wrong Report Dispatch
5 Compliance to the TAT
6 Non
Compliance rate to Panic Analyse compliacne to
Value Reportig Policy
Relevant Section of
Description Neumerators Denominators Ratio Responsibility
the Lab
Data collection : MA
Number of Needle prick
Laboratory
Number of Needle prick Number of Needle prick
Total Number of Samples Injuries
(NSI)
Facilitate to data
Injuries (NSI) reported in Injuries (NSI) reported in a month all
per month collection and approval
a month reported in a month Total Number of Samples per : HOD Laboratory /
month
Incharge laboratory
Data collection : MA
Analyse number of No of Patient Identification Laboratory
samples discarded due to Number of samples Total Number of Samples Errors x1000 Facilitate to data
discarded due to wrong all
wrong patient Patient /vial Identifications per month No of Patient Admitions Per collection and approval
identifications/ Vial month : HOD Laboratory /
Incharge laboratory
Data collection : MA
Analyse number of Number of samples discarded
Laboratory
Total Number of Samples due toincorrect collection x Facilitate to data
discarded due to incorrect per month 100 all collection and approval
interms of total number collection Total Number of Samples per
: HOD Laboratory /
of samples month
Incharge laboratory
Data collection : MA
Number of incorrect report Laboratory
Number of incorrect Number of incorrect report Total Number of Samples dispatch x 100 Facilitate to data
report dispatch dispatch per month Total Number of Samples per SampleCounter collection and approval
month : HOD Laboratory /
Incharge laboratory
Data collection : MA
No of samples deviated from Laboratory
Analyse compliacne to No of samples tested within Total Number of Samples the TAT x 100 all Facilitate to data
the TAT time policy the TAT per month Total Number of Samples per collection and approval
month : HOD Laboratory /
Incharge laboratory
Data collection : MA
No of samples deviated from Laboratory
No of samples deviated from Total Number of Samples the panic value policy x 100 all Facilitate to data
the panic value policy the panic value policy per month Total Number of Samples per collection and approval
month : HOD Laboratory /
Incharge laboratory
 NUMBER OF NEEDLE STICK INJURIES (NSI)

Dec Jan Feb

Number of Needle prick Injuries (NSI) reported in a month 0 0 0

Total Number of Samples per month 6654 6622 6224

Hospital Target 0 0 0
 SAMPLES THAT COULD NOT BE PROCESSED
DUE TO INCORRECT PATIENT
INFORMATION/VIAL

Dec Jan Feb

Number of samples discarded due to wrong Patient /vial Identifications 0 0 0
Total Number of Samples per month 6654 6622 6224
Rate 0 0 0
Hospital Target 0 0 0
NUMBER OF SAMPLES DISCARDED DUE
TO INCORRECT COLLECTION

Dec Jan Feb

Number of samples discarded due to incorrect collection 0 0 0
Total Number of Samples per month 6223 6796 6502
Samples That Could Not Be Analyzed Due to an Incorrect
0 0 0
Collection
Hospital Target 0 0 0
COMPLIANCE TO THE TAT
100

90

80

70
Compliance to TAT

60

50 Compliance to the TAT

40

30

20

10

0
Dec Jan Feb

Dec Jan Feb

No of samples tested within the TAT 6223 6796 6502
Total Number of Samples per month 6223 6796 6502
Compliance to the TAT 100 100 100
Hospital Target 100 100 100
 COMPLIANCE TO LABORATORY SAFETY

100

90

80

70

60

50

40

30

20

10

0
DEC JAN FEB

Compliance Rate 80 85 100

Total Compliance 105 105 105
Compliance to Laboratory Safety 76 81 95
CLINICAL INDICATORS – RADIOLOGY
Percentage of reactions to
1 the contrast during CT and
MRI
Any person can reaction to contrast. However,
by taking the patient's history before injecting
any contrast, the hospital will able to identify Number of reactions to the contrast
the allergic history and hense be able to take Number of reactions to during CT and MRI per month
No of patient received CT
the appropriate precaustions. By monitoring the the contrast during CT *1000
incidents of reactions developed due to the & MRI Scans per month
and MRI per month No of patient received CT & MRI
injection of contrast, patient's safety and the Scans per month
processes of proper pre procedure evaluation
can be monitored.

Exposure to the radiation during pregnancy can

cause developmental abnormalities in the fetus
The ratio of unaware (Teratogenic). Therefore it is a responsibility of Total Number of Pregnant Ladies
Total Number of Pregnant No of patient received
pregnant women undertaking each staff member of the department of exposed to radiation * 1000
2 radiology to avoid exposing a pregnant lady to Ladies exposed to radiological procedures
the radiological any kind of radiological investigations. by No of patient received radiological
radiation per month
investigations monitoring the number of unaware pregnant procedures per month
women being exposed to radiation of a patient
safety at the department of radiology.

All critical reports should tested in priority
3 Critical test reported on time basis. Hospital should deliver critical tests in
acceptable time.
No of critical radiological
No of critical radiological
procedures reported within
procedures reported No of critical radiological
established time frame *1000
within established time procedures per month
No of critical radiological
frame.
procedures per month

Total number of Reports given

Total number of Reports No of patient received
Reports given within the All radiological procedures should be within the turnaround time *1000
4 given within the radiological procedures
turnaround time conducted within established turn around times No of patient received radiological
turnaround time per month
procedures per month

No of patient received Total Number of wrong reports

Correct report should be dispatched to the
Persentage of of wrong Total Number of wrong dispatched
5 correct patient. This is the indicator which radiological procedures
reports dispatched shows compliance to the patient identification.
reports dispatched No of patient received radiological
per month procedures per month
The Percentage of reactions to the contrast during CT
, Fluoroscopy & MRI
100%
90%
80%
70%
60%
Persentage of reac-
50% tions to the con-
trast during CT ,
40% Flouoroscopy &
30% MRI
20%
10%
0%
December January February

December January February

Number of reactions to the contrast during CT and MRI per month 0 0 0
No of patient received CT ,Flouoroscopy, & MRI Scans per month 255 162 296
Persentage of reactions to the contrast during CT , Flouoroscopy & MRI 0% 0% 0%

Hospital Target 0% 0% 0%
THE PERCENTAGE OF UNAWARE PREGNANT
WOMEN UNDERTAKING THE RADIOLOGICAL
INVESTIGATIONS

December January February

Total Number of Pregnant Ladies exposed to radiation 0 0 0
No of patient received radiological procedures per month 3018 2372 1856
Percentage of unaware pregnant women undertaking the radiological
investigations 0% 0% 0%
Hospital Target 0% 0% 0%
 COMPLIANCE WITH TURNAROUND TIME

100%

90%

80%

70%
Compliance Rate

60%

50% Urgent reports given

within the turnaround t...
40%

30%

20%

10%

0%
December January February

Month December January February

Total number of Reports given within the turnaround time 404 318 224
No of patient received radiological procedures per month 404 318 224
Urgent reports given within the turnaround time 100% 100% 100%
Hospital Target 100% 100% 100%
COMPLIANCE WITH TURNAROUND TIME- NON
URGENT

Month Dec-22 Jan-23 Feb-23

Total number of Reports given within the turnaround time 2506 1968 1521
No of patient received radiological procedures per month 2614 2054 1632
Reports given within the turnaround time 95.9 95.8 93.2
Hospital Target 100% 100% 100%
PERCENTAGE OF WRONG REPORTS
DISPATCHED

December January February

Total Number of wrong reports dispatched 0 0 0
No of patient received radiological procedures per month 3018 2372 1856
Percentage of wrong reports dispatched 0% 0% 0%
Hospital Target 0% 0% 0%
CLINICAL INDICATOR ANALYSIS- BIO
MEDICAL ENGINEERING
50

40

30

20

10 Received
Repair Jobs
0 Completed
0 22 0 22 0 22 0 23 0 23 0 23 Repair Jobs
r -2 r -2 r -2 -2 -2 -2
be be be ar
y
ar
y ch
u u ar
cto em em Ja
n br M
O o v ec F e
N D

Months Received Repair Jobs Completed Repair Jobs Accuracy

October - 2022 34 32 94.1
November - 2022 35 31 88.6
December - 2022 45 36 80.0
January - 2023 30 26 86.7
February - 2023 50 34 68.0
March - 2023 30 16 53.3
COMPLETION OF BIO MEDICAL EQUIPMENT
SERVICES

Duration Scheduled Services Completed Services Accuracy

1ST Quarter (Jan to March) 106 100 94.3
CLINICAL INDICATORS – CSSD

Missing Items No of packed No of Incidet reported

No of Incident
1 in received prepared per No of packed prepared per Zero
reported
pack month month

No of packed No of Items re Auto Claved

Re-autoclave No of Items re
2 prepared per No of packed prepared per Zero
Items Auto Claved
month month
CSSD
RATE OF RE -AUTOCLAVE

Dec Jan Feb

No of Incidet Reported 0 0 0
No of Packed Prepared 310 312 315
Rate of Re -Autoclave 0 0 0
Hospital Target 0 0 0
CSSD -MISSING ITEMS IN RECEIVED PACK

Dec Jan Feb

No of Incidet reported 0 0 0
No of packed prepared per month 310 312 315
No of Missing item received per pack 0 0 0
Hospital Target 0 0 0
OUT PATIENT DEPARTMENT
Efficiency and Cleanliness of OPD

100
90
80
70
60 Efficiancy and Cleanliness of
OPD
50
40
30
20
10
0
Jan Feb

Jan Feb
No of Patients Satisfied with the Service 215 295
No of Feedback Collected 220 300
Efficiancy and Cleanliness of OPD 98 98
BLOOD BANK

Types of Transfusion Reactions and

their Frequency

6% Febrile non- Hemolytic Transfusion reaction

6%
Minor allergic/urtcarial reactions
6%
Isolated Acute Hypotensive Transfusion Reaction
Transfusion Associated Circulatory Overload and Heart
50% Failure
ACEI related isolated hypotension

33%
TRANSFUSION REACTIONS RELATING TO
EACH TYPE OF COMPONENT

ISSUES REACTIONS DEATHS

1622

358 389

95
19 0 1 0 2 2 16 0 0 0 0
RCC Platelet FFP CPP CRYO
PLAN FOR CLINICAL INDICATOR ANALYSIS
UHKDU Master list of Clinical Indicators.xlsx