| Bil. |
Tittle |
Standard/ Optimum |
Pre audit |
Intervention/ Action/ Change of Practice |
Re-audit post intervention etc. |
| 1. |
Blood Culture Volumes in Adult Patients at HoSHAS |
≥ 80% of optimum blood volume (8-10 ml) |
20% |
Promote awareness & Spread knowledge:
1. CME
2. Roadshow
3. Putting calibrated mark at culture bottles |
78% |
| 2. |
VTE Risk Score Within 24 Hours of Normal Delivery |
100% |
52-62% |
1. CME
2. Briefing to new Mos & Hos
3. Constant reminders in whatsapp group
4. Improvision of Postnatal Review Template
(available in every PC in LR) |
100% |
| 3. |
To Assess Compliance of Central Line Bundle in NICU
1. Correct type of disinfectant
2. Correct technique of disinfectant
(air dry 30 seconds)
3. Correct steps of central line insertion |
≥95% |
22.90% |
1. Provide correct type of disinfectant
2. Monthly CME to MO
3. Checklist for Central Line Care Bundle crossverified by nurse in charge prior insertion
4. Supervisions by paediatrician incharged during procedure |
95% |
| 4. |
Audit Kepatuhan Senarai Semak Penilaian Risiko Pemeriksaan Pendengaran Neonatal Dalam Kalangan Petugas Saringan Pendengaran Bayi (PSPB) |
100% |
79.5%-89.8% |
1. Menghasilkan video ringkas tentang tatacara prosedur
2. Menyediakan carta alir berkaitan prosedur yang lebih mudah difahami
3. Mengedarkanrislah cara pengisian data saringan pendengaran bayi kepada PSPB
4. Melakukan pemeriksaan peralatan dan pemerhatian terhadap PSPB ketika melakukan ujian saringan sebanyak 1-2 kali sebulan |
100% |
Utama
