S.

No OE Code
1 AAC 6.c
2 COP 5.b
3 COP 6.e
4 COP 8.f
5 COP 8.g
6 COP 9.h
7 COP10.e
8 COP 11.e
9 COP 11.g
10 COP 12.g
11 COP 17.d
12 MOM 3.e
13 MOM 4.a
14 MOM 4.c
15 MOM 4.e
16 MOM 5.c
17 MOM 9.e
18 PRE 1.d
19 PRE2.h
20 PRE 3.g
21 PRE 5.c
22 PRE 5.f
23 PRE 7.d
24 PRE 8.a
25 PRE 8.b
26 PRE 8.c
27 PRE 8.e
28 HIC 4.e
29 PSQ 1.b
30 PSQ 3.h
31 PSQ 4.b
32 PSQ 4.c
33 PSQ 6.a
34 PSQ 6.f
35 PSQ 7.e
36 FMS 2.c
37 FMS 3.f
38 FMS 7.b
39 FMS 7.d
40 HRM 3i
41 IMS 7.e
less men power
Roles and Responsibilities of the team members not defined same observared during moch dril
Nursing care plan was not according to actual needs of patient as seen in some of the sampled files
TAT was defined for blood and blood component
Blood reactions are not analysed hence CAPA was not done
Documentation of the patient condition is not evidenced in the counseling records
obstretic patient does not include thmaternal nutritional assessment
Immunization charts for IP and OP Patients not evidenced across the HCO. Growth charts not evidenced for the IP patients ac
not available
for Ed in file 249487
pain alleviation measure or medication are initiated and titration according topatient need and response not evidence
LASA drug list to be modified and not store apart from each other unifoermly.
The medications were not written in capitals across the organization and in many areas the prescription was not legible espec
Although provision for doccumentation for alergy but that was not uniformly done.
Drug list for verbal order was not available
Medication order are Capital and name of person. date and time was not evidence
Record for narcotic drugs are Maintaining but it does not showing who has administered and who is varified. for discarding al
Availability of Compliant Box found in OPD area only. Rest of the areas like Wards ,OT and Icu s not evidenced across the HCO
How to raise and whom to raise the compliant is not evidenced across the HCO. It's available only OPD area.
Multidisciplinary councelling is not evidenced across the HCO.
Patient and Family education about Food and Drug interaction is not evidenced across the HCO
Patient and Family education about various pain management techniques is not found across the HCO
Procedure of giving feedback ad lodging complaint is found only in OPD areas. Rest of areas like IP, WARD and in ICU is not e
Effective communication with the patient and family members not evidenced across the HCO
Special situation s where enhanced communication is needed is not evidenced across the HCO.
Enhanced communication with patients is not evidenced across the HCO.
System to monitor and review the implementation of the effective communication is not evidenced across the HCO.
linen management does not defined separate protocol for soiled linen and infected linen.
The Onchology ( medical, surgical,) needs to added
undertaking QIP based on the outcome of indicator capture not evidenced.
use of appropriate anslyticsl tool not evidenced
use if appropriate statistocsl tool not evidenced in the CAPA
appropriate usage of tool and process to ensure safety culture not evidenced
Departmental targets not implememented
There were many near miss incidents in medication errors which were not effectively used in management to reduce risk
Fire signages are not according to the National Building Codes.
Spill management of chemical not upto the mark. It was found while interview of Lab Technician
Exit plan for Non Fire emergencies not displayed across the HCO.
Although there is a maintenance plan for Fire implementation of the same some of the areas in HCO smoke detectors are not
effective training RMO training on hospital formulary and the generic name dosage and dilution protocols with respect to ind
active file audit review points and deficiencies were not evidenced for example review of medication management , review
Score
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
3
2
3
3
3
3
3
3
3
3
H

New born / Pediatric booklet is prepared and introduced which contains baby details, Family history, New born examination &
Child's family members are provided with the new born booklet and are educated about the Nutrition, Immunization and Saf

Departmental level quality objectives are made for the Physiotherapy, Chemotherapy, Dialysis, OT, Blood bank, Emergency de
Assessor: NC Raised_2 HCO: CAPA Submitted_2 Assessor: Final Remark Final Score NC Status
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
or both IP and OP patients. Separate growth charts are used for IP patients for both boy and girl4 Closed
iatric booklet sample evidences enclosed. 4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
shared with all the departmental staff and regular feedback is taken in the committee meeting. 4O Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
4 Closed
NC/OBSN
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
NC
appoinment [Link]
CODE BLUE MOCK DRILL SHEET & [Link]
NURSING HISTORY AND INITIAL ASSESSMENT [Link]
BLOOD AND BLOOD COMPONENT TAT [Link]
BLOOD TRANSFUSION REACTION INCIDENT [Link]
FAMILY BRIEFING [Link]
ANTENATAL & MATERNAL NUTRITION [Link]
GROWTH CHART -[Link]
CHILDS FAMILY EDUCATION [Link]
DISCHARGE CRITERIA DISPLAY - [Link]
PAIN ASSESSMENT [Link]
LASA [Link]
CIRCULAR ON RATIONAL PRESCRIPTION OF [Link]
CIRCULAR ON RATIONAL PRESCRIPTION OF [Link]
VERBAL ORDER DRUG LIST [Link]
CIRCULAR ON RATIONAL PRESCRIPTION OF [Link]
NARCOTIC REGISTER ATTENDANCE .pdf
FEEDBACK AND LODGING COMPLAINT PROCEDURE [Link]
PATIENT FEEDBACK & LODGING COMPLAINT [Link]
FAMILY BRIEFING [Link]
DRUG FOOD INTERACTION [Link]
PAIN MANAGEMENT EDUCATION EVIDENCE [Link]
FEEDBACK AND LODGING COMPLAINT PROCEDURE [Link]
COUNSELLING RECORD SAMPLE [Link]
COUNSELLING ROOM [Link]
COUNSELLING ROOM [Link]
COUNSELLING ROOM [Link]
HIC MANUAL - LINEN AND LAUNDRY [Link]
MEDICAL ONCOLOGY [Link]
PRESCRIPTION AUDIT APRIL [Link]
ANALYTICAL & STATISTICAL TOOLS USAGE FOR RCA AND [Link]
ANALYTICAL & STATISTICAL TOOLS USAGE FOR RCA AND [Link]
PATIENT SAFETY AUDIT [Link]
DEPARTMENTWISE [Link]
QIP Medication [Link]
FIRE [Link]
HAZARDOUS SPILL MOCKDRILL [Link]
EMERGENCY EVACUATION PLAN (FIRE & NON-FIRE) DISPLAY [Link]
DAILY PM CHECKLIST FOR FIRE [Link]
HOSPITAL DRUG FORMULARY & APPROPRIATENESS OF PRESCRIPTION TRAINING ATTENDANCE [Link]
ACTIVE FILE AUDIT CHECKLIST [Link]
CV & [Link]
CODE BLUE MOCKDRILL [Link]
NURSING INITIAL ASSESSMENT WITH UPDATED NURSING CARE [Link]
BLOOD AND BLOOD COMPONENT TAT REGISTER [Link]
BLOOD TRANSFUSION REACTION INVESTIGATION [Link]
PATIENT & FAMILY COUNSELLING IN [Link]
MATERNAL NUTRITION ASSESSMENT FOR OBSTRETIC [Link]
IMMUNIZATION IP [Link]
CHILDS FAMILY EDUCATION ON NUTRITION, IMMUNISATION & SAFE [Link]
DISCHARGE CRITERIA [Link]
PAIN ASSESSMENT [Link]
LASA [Link]
PRESCRIPTION [Link]
IP [Link]
VERBAL ORDER [Link]
PRESCRIPTION [Link]
NARCOTIC REGISTER [Link]
GUIDLINESS PATIENT FEEDBACK & LODGING COMPLAINT [Link]
PROCESS ON HOW TO VOICE A COMPLAINT [Link]
MULTIDISCIPLINARY COUNSELLING [Link]
DRUG FOOD INTERACTION TRAINING [Link]
PAIN MANAGEMENT TECHNIQUES [Link]
PATIENT FEEDBACK & LODGING COMPLAINT [Link]
EFFECTIVE COMMUNICATION [Link]
COUSELLING RECORDS [Link]
DAILY COUNSELLING RECORDS & MDT [Link]
DAILY COUNSELLING RECORDS & MDT [Link]
LINEN MANAGEMENT [Link]
ONCOLOGY AUDIT [Link]
PRESCRIPTION AUDIT JUNE [Link]
INCIDENCE REPORTING SYSTEM AND [Link]
INCIDENCE REPORTING SYSTEM AND [Link]
PATIENT SAFETY AUDIT [Link]
DIALYSIS [Link]
QIP [Link]

HAZARDROUS MOCK [Link]

EMERGENCY EVACUATION PLAN (FIRE & NON-FIRE).pdf
FA & PA SYSTEM CHECKLIST FOR FIRE [Link]
INDUCTION TRAINING [Link]
ACTIVE FILE AUDIT [Link]
Evidence_Submitted_1
DUTY [Link]
CODE BLUE ROLES & [Link]
TRAINING ATTENDANCE [Link]
BLOOD AND BLOOD COMPONENT TAT TRAINING [Link]
BLOOD TRANSFUSION TRAINING ATTENDANCE [Link]
PATIENT & FAMILY COUNSELLING [Link]

IMMUNIZATION OP [Link]

TRAINING ATTENDANCE ON DISCAHRGE CRITERIA [Link]

TRAINING ON PAIN [Link]
LOOK A LIKE DRUG [Link]
PRESCRIPTION [Link]
IP [Link]
VERBAL ORDER TRAINING ATTENDANCE [Link]
PRESCRIPTION [Link]
NARCOTIC TRAINING [Link]
TRAINING ON FEEDBACK & LODGING [Link]
TRAINING ON COMPLAINT PROCESS & [Link]
MULTIDISCIPLINARY COUNSELLING [Link]
FOOD DRUG INTERACTION EDUCATION [Link]
PAIN MANAGEMENT TECHNIQUES [Link]
TRAINING ON FEEDBACK & LODGING [Link]
EFFECTIVE [Link]
ENHANCED & EFFECTIVE [Link]
EFFECTIVE [Link]
EFFECTIVE [Link]
LINEN MANAGEMENT PRE & POST [Link]
ONCOLOGY [Link]
PRESCRIPTION AUDIT MAY [Link]
QIP Medication [Link]
QIP Medication [Link]
PATIENT SAFETY [Link]
ONCOLOGY [Link]
Risk Management [Link]

HAZMAT SPILL TRAINING & PRE-POST [Link]

FACILITY MAINTANANCE HISTORY [Link]

PRE & POST TEST ON APPROPRIATENESS OF [Link]
DISPLAY OF ABBREVIATION [Link]
Evidence_Submitted_1

PRE & POST TEST CODE [Link]

PATIETN & FAMILY COUNSELLING IN ICU [Link]

SOUND A LIKE DRUG [Link]

PRESCRIPTION [Link]
IP [Link]

PRESCRIPTION [Link]
NARCOTIC [Link]

PATIENT & FAMILY COUNSELLING AND EFFECTIVE COMMUNICATION [Link]

FOOD DRUG INTERACTION EDUCATION [Link]
PAIN MANAGEMENT TECHNIQUES [Link]

MULTIDISCIPLINARY COUNSELLING [Link]

MULTIDISCIPLINARY COUNSELLING [Link]
FAMILY BRIEFING [Link]
FAMILY BRIEFING [Link]
LINEN MANAGEMENT [Link]
Patient Safety Program for Medical & Surgical [Link]
QIP Medication [Link]
TRAINING ATTENDANCESHEET STATISTICAL & ANALYTICAL TOOLS FOR QUALITY IMPROVEMENT [Link]
TRAINING ATTENDANCESHEET STATISTICAL & ANALYTICAL TOOLS FOR QUALITY IMPROVEMENT [Link]
PATIENT SAFETY PRE & POST [Link]
PHYSIOTHERAPY [Link]
TRAINING [Link]

HAZMAT [Link]

SMOKE DETECTORS IN MRD AND [Link]

PRE & POST TEST ON HOSPITAL DRUG [Link]
TRAINING ATTENDANCE SHEET FOR ACTIVE FILE AUDIT [Link]
TRAINING [Link]

TRAINING ATTENDENCE & PRE-POST TEST ON PRESCRIPTION, [Link]

IP [Link]

PRESCRIPTION [Link]
NARCOTIC USAGE AND DISCARD [Link]

FOOD DRUG INTERACTION [Link]

PATIENT EDUCATION ABOUT PAIN MANAGEMNET TECHNIQUES [Link]

PATIENT & FAMILY COUNSELLING AND EFFECTIVE COMMUNICATION [Link]

PATIENT & FAMILY COUNSELLING AND EFFECTIVE COMMUNICATION [Link]
PATIENT & FAMILY COUNSELLING AND EFFECTIVE COMMUNICATION [Link]
TRAINING TO HOUSEKEEPING AND [Link]
TRAINING ON CHEMOTHERAPY PATIENT SAFETY [Link]
QIP [Link]
TRAINING PPT ON STATISTICAL TOOLS AND [Link]
TRAINING PPT ON STATISTICAL TOOLS AND [Link]
PATIENT SAFETY TRAINING [Link]
Vasavi Hospitals Mail - Quality Indicators [Link]

MANAGEMENT OF HAZARDOUS [Link]

Evidence_

TRANSCRIPTION & PRESCRIPTION [Link]

IP [Link]

PRESCRIPTION [Link]

FOOD DRUG INTERACTION PAMPHLET [Link]

POLICY ON RIGHT TO INFORMATION & [Link]

TRAINING [Link]
Evidence_Submitted_2