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Significant Unexpected Findings - Dec, 24

The audit report from Shaukat Khanum Memorial Cancer Hospital evaluates the compliance of timely communication of critical results in cerebrospinal fluid cases for December 2024. Out of 369 cases, 4 critical results were identified and communicated promptly, achieving a compliance rate of 100% across all months of the audit. The overall status of the audit is satisfactory with no non-conformance or corrective actions required.

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Amna Habib
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10 views2 pages

Significant Unexpected Findings - Dec, 24

The audit report from Shaukat Khanum Memorial Cancer Hospital evaluates the compliance of timely communication of critical results in cerebrospinal fluid cases for December 2024. Out of 369 cases, 4 critical results were identified and communicated promptly, achieving a compliance rate of 100% across all months of the audit. The overall status of the audit is satisfactory with no non-conformance or corrective actions required.

Uploaded by

Amna Habib
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© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Shaukat Khanum Memorial Cancer Hospital Researeh Centre Audit Report R/DEP/PATH(All)-059/v.2 Date: 01-01-2025 Title: Significant Unexpected Findings Supervised by: Dr. Maryam Hameed (Section Head, Consultant Pathologist) and Dr. Shaarif Bashir (Senior Instructor Pathology) Auditors: Maliha Mazhar (Junior Medical Technologist) Audit Frequency: Monthly Standard: CYP.06450-Significant and unexpected findings (communicated to the responsible clinician and record of those communications are retained) COM.30000 Critical results notification (The lab immediately notifies physicians or other clinical personnel responsible for patient's care when results of designated test exceed established critical value. Records of noti tion are retained. COM.30100 Critical results read-back (for verbally communicated critical results personnel communicating request and record read-back of the results) Objective: The audit is to check the compliance of communication of critical results in timely manner and maintain record for communication with read-back of critical results. Target: 100% Duration: 1* December to 31* December 2024 Rationale: To check the compliance of timely communication of significant unexpected findings in cerebrospinal fluid cases to physicians. Total Number: Among 369 cases, 4cases of critical result were found, alert was informed to relevant concerns timely. RIDEPIPATH(AI)-059/v.2 Page 1 of 2/Page Shaukat Khanum ‘Memorial Cancer Hospital and Research Centre ‘Audit Report RIDEP/PATH-O59(AII)Wv.2 Audit Summary: Jan, |Feb, |Mar, | Apr, | May, |June, | July, | Aug, | Sep, | Oct, | Nov, | Dec 24 [24 [2a [2a 2a | 24 2a [24 [2a 2a 2a 2a Total number | 6 2 3 1 5 8 6 1 6 2 7 4 of cases Compliance | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% | 100% 3 3 5 ec,23 4an24 Feb; Mar,24 Apr,24 May,24 June,2 Juy,24 Aug.24 Sep,24 Oct,24 Nov,24 Dec,24 Months Non-Conformance: Not applicable Reasons: Not applicable Corrective Actions: Not applicable Effective Review: Not applicable Status: Satisfactory Bits. {fbr Signature Auditor Signature- Supervised By RIDEP/PATH(All)-059/v.2 Page 2of 2|P age

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