Clinical Audit Proposal Form

Hospital Proposal Form for A Clinical
Audit Project
Title of clinical audit: Audit of blood products transfusions and analysis to enable better
management of blood products for surgeries at DNSH
Name & title of the health care professional taking responsibility for this project.
Name: Dr. Manish Tandon

Designation: Senior Consultant & Head, Dept. of Anaesthesiology
E-mail Address: Manish.tandon.dr@narayanahealth.org
Mobile No:
Is there a multi- Name Specialty Designation
professional 1 Dr Shamsuz Zaman Immunohematology and Consultant Incharge
involvement in the Blood Transfusion Blood bank Services,
project? If yes, DNSH
please list the 2
names, specialty 3
and designation of
those involved. 4
5
6
1. Is it a standard based audit? If so, is it based on the following?

If you answer ‘YES’ to any of the questions below, please provide the required information in
the space provided.
a. Compliance with an international

guideline
Y N √
b. Compliance with a national guideline
Y N √
c. Compliance with NABH

standards/guideline
Y N √
d. Compliance with your hospital’s policy

and procedure
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Dharamshila Marg, Vasundhara Enclave, Near New Ashok Nagar Metro Station, Delhi 110 096 Format No. DNSH/CA/001
Y N√
2. Is it an audit based on?

If you answer ‘YES’ to any of the questions below, please provide the required information in
the space provided.
a. Perceived clinical risk
Y N √
b. Adverse / Sentinel Event Occurrence
Y N √
c. Patient Complaint
Y N √
d. Complaint from Other sources
Y N √
e. Patient feedback survey
Y N √
3. Is it a re-audit?
Yes No √
If yes, please specify the

reason:
Scope of The Audit:
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Indicate whether the audit will be in your department, in some other department or involves
multiple departments, kindly list the departments audited in the space provided:
1. Operation Theatre
2. Blood Bank
3.
4.
1. Red blood cell transfusion: a clinical practice guideline from the AABB
2.
3.
Objectives of the Project: Formulation of DNSH Maximum Surgical Blood Order Schedule
(MSBOS)
List the evidence-based standards for the clinical audit project:
Please give the name of the guideline/standard/policy and procedure:
As above
Has a copy or a link to guideline or standard or policy & procedure been enclosed? Y/N Y
https://pubmed.ncbi.nlm.nih.gov/22751760/
Note:It is not enough just to provide a reference to a published article, or a guideline or protocol.
Individual standards of best practice that the audit will be based on should be listed below or appended
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Outline of The Audit Project Methodology:
a. Will the project be Retrospective √
Prospective
b. What are the criteria Inclusion criteria: Patients Operated for different surgical
for selecting cases to procedures at DNSH for whom blood products were arranged and
be included in the / or transfused perioperatively.
project?
Exclusion criteria: Patients managed medically and not operated

upon and requiring transfusion of blood and blood products
Patients operated for various indications at DNSH

c. How Will the Cases Be
Identified?
d. What Is the Target

Sample Size? 200 Blood orders for surgeries at DNSH
e. Is this the target

All cases within specified time period 3months
sample size (Tick the
appropriate)
A sample of them
f. What sources will be Records of Operation theatre and Blood Bank and Surgical and
used to obtain the Anaesthesia notes
data?
(for example, patient notes,
emergency patient record,
information system, etc)
g. Have the data N
collection tools
devised for the study
enclosed? Y/N
h. When will it start?
i. What is the expected

4 Months
duration?
j. will the results be

No
collated?
k. When will the results

At End of data collection which will take 3 months
be analysed?
l. When will the
recommendations be
made? After Analysis of the collected data, expected by 4 months from
beginning of data collection.
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Tentative Month/Date:
m. When will it be
submitted to the
clinical audit
committee for review?
n. Are you considering No

 Publishing the results
of this project?
 Presenting the results
outside NH?
o. Who will be
responsible for Blood Bank
ensuring that
recommendations
from this audit are
implemented?
This section must be completed by the senior person taking responsibility for the audit
I agree to take responsibility for ensuring that the audit is completed, reported and an
action plan is devised to implement recommendations arising from the audit.
Name of the person taking responsibility:
Signature:
Date:
This section must be completed by the Clinical Audit Committee:
a. Does the project meet the definition

of clinical audit?
b. Is the project important for the

department or organisation? If so
why?
c. Is any special permission or
requests needed?
If so what are they?
d. Are there any special remarks by
the clinical audit committee?
Signature of Chairman Of Clinical Audit
Committee
Name
Date
5|Page

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Hospital Proposal Form for A Clinical

Name: Dr. Manish Tandon

1. Is it a standard based audit? If so, is it based on the following?

a. Compliance with an international

b. Compliance with a national guideline

c. Compliance with NABH

d. Compliance with your hospital’s policy

2. Is it an audit based on?

a. Perceived clinical risk

b. Adverse / Sentinel Event Occurrence

d. Complaint from Other sources

e. Patient feedback survey

If yes, please specify the

Scope of The Audit:

List the evidence-based standards for the clinical audit project:

Please give the name of the guideline/standard/policy and procedure:

a. Will the project be Retrospective √

Exclusion criteria: Patients managed medically and not operated

Patients operated for various indications at DNSH

d. What Is the Target

e. Is this the target

h. When will it start?

i. What is the expected

j. will the results be

k. When will the results

n. Are you considering No

This section must be completed by the Clinical Audit Committee:

a. Does the project meet the definition

b. Is the project important for the

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