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Clinical audit

Clinical audit is a way to find out if healthcare is being provided in line with standards and lets the Trust and it's patients know where their service is doing well, and where there could be improvements.

The aim of clinical audit projects is to allow improvement to take place where it will be most helpful and will improve outcomes for patients. Clinical audit projects look at care both at a national level, and locally within the Hospital itself.

The Clinical Audit and Risk Management Department at CMFT help medical and nursing staff to undertake hundreds of clinical audits each year.

Clinical staff identify areas where they think improvements can be made and then carry out an audit. They look at the best standard of care and use that as a measurement. Sometimes they will look at new standards, or standard from NICE in order to improve the care and treatment their service provides.

Where an audit finds a need for improvement the staff undertaking the audit will agree how this can be achieved by way of an action plan.

Below we are provide a list of the clinical audit projects that have been completed by the Trust in the last 3 months.


Audit Title Directorate Date Closed
Diagnosis and Management of Preterm Rupture of Membranes Obstetrics 03/04/2017
Time Taken to Complete Police Statements Sexual Assault Referral 04/04/2017
Results Management process in the Whitworth Clinic Gynaecology 06/04/2017
Out Patient Prescriptions Pharmacy 07/04/2017
Controlled Drugs in Community / District Nursing Pharmacy 07/04/2017
Lubrication of Dental Handpieces and motors Community Adults And Specialist Services 19/04/2017
Ankle Fracture operative verses non operative management Surgery, Trauma & Orthopaedics (Trafford) 20/04/2017
Use of Platelets and Wastage in Cardiac Surgery Laboratory Medicine 21/04/2017
Oxygen prescribing at Trafford Hospital Medicine & Rehabilitation 21/04/2017
Staff knowledge of the Mental Capacity Act Medical Directors Team 24/04/2017
Training of Members of Staff on Restorative X-rays Dental Hospital 25/04/2017
Orthodontic New Patient Referrals from Primary Care in to the UDHM Dental Hospital 25/04/2017
Newborn Bloodspot Screening (Health visiting) Community Children's Services 26/04/2017
Handling of Medicines for Transfer on Discharge Form Pharmacy 27/04/2017
Intraoperative Monitoring Annotation Neurophysiology 27/04/2017
Frailty and Cognitive Assessments In Critical Care Surgical Patients Critical Care (MRI) 27/04/2017
Rapid Sequence Induction Critical Care (MRI) 27/04/2017
Testicular Tumour Reporting Laboratory Medicine 27/04/2017
Body Mass Index recording and appropriateness of referrals to dietetic services. Dental Hospital 27/04/2017
Referral criteria for children undergoing Cone Beam CT [CBCT] Examination Dental Hospital 27/04/2017
Hand Hygeine Laboratory Medicine 28/04/2017
The Medical Emergency Team: Hospital Outcomes after a day (METHOD) Audit (EWS Standards) Critical Care (MRI) 28/04/2017
Quality of Accident and Emergency (A&E) Referrals for Radiological Examinations Radiology 28/04/2017
Compliance with BSA national guidance in our Paediatric Tinnitus clinic (Baseline Audit) Community Children's Services 04/05/2017
"All children with asthma should have an written action plan along with an inhaler technique check during face to face consultations with the asthma nurse" Community Children's Services 05/05/2017
Microsuction Clinics at Longsight Health Centre Community Children's Services 10/05/2017
The management of patients with INR >5 Haematology And Gastroenterology 10/05/2017
Preventing inpatient falls: the measurement of lying & standing blood pressure Medicine & Rehabilitation 11/05/2017
Induction and Competency Framework Audit for Clinical Research Nurses Division-Wide 16/05/2017
VTE Risk Assessment and Management on the Stroke Unit Medicine & Rehabilitation 16/05/2017
Adult Emergency Department Antidotes Audit Urgent Care 17/05/2017
Medical Handover Practice Medicine & Rehabilitation 18/05/2017
Management of Acute Upper GI Bleeds in the Emergency Department (CDSG; Student Project) Urgent Care 22/05/2017
Surgical Antibiotic Prophylaxis [Adults] Pharmacy 23/05/2017
Unlicensed Medicines Policy Pharmacy 23/05/2017
Temporal Artery Biopsy Ophthalmology 23/05/2017
Pain Assessment and Provision of Analgesia in Post-operative Neonates Newborn Intensive Care 25/05/2017
Safe Guarding Newborn Intensive Care 25/05/2017
Secondary Prevention of Osteoporotic Fractures Surgery (Trafford) 26/05/2017
TPMT testing for Thiopurine Drug Therapy [NICE CG152] Laboratory Medicine 30/05/2017
Medicines Security Checks in Learning and Disability (MDLP) Pharmacy 30/05/2017
Handling of Controlled Drugs in Intermediate Care Bed Base Service Pharmacy 30/05/2017
Cephalometric Diagnostic Quality- Patient Positioning and Collimation Dental Hospital 30/05/2017
Intubation Documentation Newborn Intensive Care 30/05/2017
Are we prescribing bitewing radiographs in line with national guidelines? Community Adults And Specialist Services 01/06/2017
Treatment of Iron Deficiency in Paediatric Inflammatory Bowel Disease Medicine 2 (RMCH) 05/06/2017
Non Medical Prescribing Trust-Wide 06/06/2017
Improving Quality Programme (IQP) Audit Trust-Wide 12/06/2017
Annual Trust Consent Audit Trust-Wide 13/06/2017
Medication Safety & Storage Nursing Behavioural Factors Trust-Wide 13/06/2017
Metastatic Spinal Cord Compression Adult Integrated Medicine 14/06/2017
Ionising Radiation (Medical Exposure) Regulations (IRMER) [Adults] Radiology 15/06/2017
Nutritional Management of Out-Patients with Chronic Kidney Disease (CKD) Stage 5 - Patients Undergoing Peritoneal Dialysis (PD) Allied Health Professionals 15/06/2017
Routine EEG with Video Protocol in RMCH Neurophysiology 15/06/2017
Ionising Radiation (Medical Exposure) Regulations (IRMER) Radiology 15/06/2017
Postoperative analgesia prescribing audit Theatres & Anaesthesia (Childrens) 16/06/2017
Gillick consent process Community Children's Services 20/06/2017
Community Adults Record Keeping Community Adults And Specialist Services 21/06/2017
Impact of Calliper Position of Bladder Volume in Ultrasound Radiology 23/06/2017
Assessment of Intraventricular Haemmorhage Classification on NICU Radiology 23/06/2017
Pre-operative Haemoglobin Monitoring in Patients with Hip Fracture Surgery, Trauma & Orthopaedics (Trafford) 23/06/2017
Management of Diabetes in Adult Surgical Patients Anaesthesia 27/06/2017
Percutaneous Ablation of Lung Tumours Radiology 29/06/2017
Reporting of Skeletal Surveys Performed for Suspected Non Accidental Injury Radiology 29/06/2017
Chest Radiographs for Lung Cancer Radiology 29/06/2017
Pre-operative Notes Review + Postponded Surgery [Trafford] Anaesthesia 29/06/2017
Interventional Radiology WHO Surgical Safety Checklist Radiology 29/06/2017
Controlled Drugs in Clinical Areas Pharmacy 30/06/2017
Potassium Intravenous Policy Pharmacy 30/06/2017
Acute Kidney Injury - Creatinine Assessment in Critical Care Critical Care (MRI) 30/06/2017
Prescribing Standards Pharmacy 30/06/2017
Paediatric MR Spine Technique Radiology 30/06/2017
Handling of Medicines on Transfer between Care Settings (Intermediate Care to GP) Pharmacy 30/06/2017
Gastrointestinal Specimens Booked into the Adult Histopathology Department under the "HSC 205" Suspected Cancer Pathway Laboratory Medicine 30/06/2017
Medication Review Documentation CAMHS 30/06/2017
Ablation procedures in patients with adult congenital heart
disease (ACHD)
Manchester Heart Centre 30/06/2017


If you wish to receive a copy of one of the reports on this list please contact the clinical audit department on 0161 2764172 or by e-mailing clinical.audit@cmft.nhs.uk


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