Percentage of Transfusion reactions Type of transfusion administered S.

No Date Name o f Patient Patient ID No Whole Blood Blood components Whether transfusion reaction occurred Whole Blood Yes No Blood components Yes No

Percentage of Wastage of blood component

Type of blood and blood components S. No Date patient Name patient ID Whole blood Blood components Platelets RBC Plasma Reason for wastage Signature

Incidences of Fall S. No. Date Name of patient patient ID Department name Status of the patient Conscious Semi Conscious Un Conscious Reason for fall Action taken Signature

Incidences of bed sores after admission Reason for bed sore Delay in patient prescribing Date of Condition the patient ID Diagnosis Inadequate on admission Delay in required nursing admission diagnosis medicine care by the treating doctor Action taken

S .No

Name of patient

Any other

Signature

Percentage of employees provided pre exposure prophylaxis Type of immunization S .no name of employee employee Department Designation ID Hepatitis B 1 st dose 2nd dose 3rd dose Booster Typhoid TT Remark Signature

Bed Occupancy Rate S. No. Date Total no of Beds available in the hospital in Total no of beds occupied in the 24 hrs hospital in a month. Signature

Equipment Down Time total Time when number Time when Date when Date the of hours the the Reason for non when the equipment when Equipment equipment functioning of Equipment becomes equipment was down becomes equipment functional is non was down (T1) functional functional (T2) (T1-T2)

Sr. No.

Name of Equipment

Name of department

Signature

Time taken for discharge of inpatient Time when Time when patient patient file left the was sent for room/ward/Hospital T2-T1 (in billing( T1) ( T2) mins)

Sr. No.

Date

Patient Name

Patient ID

Remarks

Signature

Number of sentinel events Name of the Date patient Patient ID Type of Event Department Near Miss Adverse Sentinel Remark Action taken

S No

Signature

Number of security related incidents including thefts Type of security related incident S No Date Theft Abuse emergency situations Any other Yes Complaint registered No

registered by

Action taken

Signature

Incidents of Needle Stick Injury Name of staff Reason for acquiring the injury Action Taken

S No

Date

Patient ID Department name

Signature

Time taken for initial assessment inpatient Time Time Time when when when patient patient patient was was was received examined examine by the by Nurse d by nursing ( T2) Doctor ( staff in T3) Patient the ward T2-T1 T3-T1 Patient Name ID ( T1) mins mins Time gap between the Initial Assessment done and the patient received by the nursing staff within More than 30 30 minutes minutes

S. No.

Date

Remarks

Signature

Time taken for initial assessment inpatient in emergency Time when Patient reported to the casualty (T1) Time when patient was examined by Nurse (T2) Time when patient was examined by Doctor T3-T1 (in T2-T1 (T3) minutes) (mins)

Sr. No.

Date

Patient ID

Patient Name

Remarks

Signature

Percentage Accidental removal of tubes and catheters Date and Time when Patient was catheterized /Tube was inserted Date and Time when catheter/tube Reason for was accidentally accidental removal Signature of removed of catheter/ Tube Nursing Staff

Sr. No.

Date

Patient Name

Patient ID Department

Incidence of Haematoma at punture site Type of procedure undertaken Minor Major Reason for the formation of haematoma

Sr. No.

Date

Patient Name

Patient ID

Department

Signature of Nursing Staff/ Technicians

Percentage of medication Errors Sr. No. Date Patient Name Patient ID Diagnosis Department name Medication Reason for Errors reported medication Error Signature of nursing Staff

Incidences of Adverse drug Reaction Adverse drug reaction reported Reason for adverse drug reaction Signature of nursing Staff

Sr. No.

Date

Patient Name

Patient ID

Diagnosis