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PROJEK CLINICAL AUDIT
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PENYELARAS : DR SANDIE EWE
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NOJABATAN/ UNITTAJUK PROJEKDESKRIPSI PROJEKSTATUS PROJEKTARIKH MULA (BULAN & TAHUN)TARIKH AKHIR (BULAN & TAHUN)AKTIVITI YANG TELAH DIJALANKAN & TARIKHPENCAPAIAN
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1FisioterapiKeberkesanan Rawatan Pain Relief berdasarkan penurunan pain score bagi pesakit luarPenurunan pain score boleh diukur melalui salah satu KPI yang dijalankan oleh Fisioterapi di semua Peringkat negeri dan Unit Fisioterapi perlu memastikan KPI ini tercapai pada setiap bulan dan tahun. Indikator ini bertujuan untuk mengukur keberkesanan perawatan fisioterapi untuk semua pesakit luar apabila berlakunya pengurangan tahap kesakitan dalam tempoh rawatan. Peratusan pesakit luar yang mencapai pengurangan tahap kesakitan perlu diambil untuk 3 kali rawatan fisioterapi dalam tempoh 2 bulan. KPI ini perlu mencapai >80%SelesaiJan 2025Dec 202515/7/2025 : Clinical Audit WorkshopPenyertaan Pertandingan Audit Klinikal 2025 peringkat Hospital Bukit Mertajam
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2FarmasiClinical audit on practice of stat dose medications in medical ward Hospital Bukit MertajamIn general stat doses should be administered within 30 minutes from the time its ordered by physian. Despite this, many hospital struggles to deliver the dose within the time frame which leads to an incident reporting in HBM in 2024, in which streptokinase 1.5MU was administered to a patient after 2 hours post prescribing. This audit aims to ensure all stat dose medication are administered within designated time frame and to increase awareness among healthcare providers (physician, nurses, pharmacist and PPK) to adhere to the time frame in order to maintain quality care of patients.1st cycle intervention executionMac 2025Johan Pertandingan
Audit Klinikal 2025
Hospital Bukit Mertajam
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3OftalmologiAudit on waiting time of Inpatients' Referral in Eye Clinic HBMPresented in MOSC (25-27 April 2025)
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4PsychiatryNational Psychiatry Clinical AuditFinishedAugust 2025December 2025Submitted to National Psychiatry Clinical Audit Committee on 5/12/25
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5Infection controlHealth Technology Assessment (HTA) for Reuse Vs Single Use of Selected DeviceProjek ini dijalankan melalui pendekatan Health Technology Assessment (HTA) bagi menilai keberkesanan dan risiko jangkitan berkaitan penggunaan semula berbanding peranti single-use terpilih. Ini bertujuan mengurangkan risiko jangkitan berkaitan penjagaan kesihatan melalui pengurangan amalan penggunaan semula peranti single-use yang berisiko.SelesaiAug 2025Oct 202528/4/2026: Clinical Audit Workshop-Tempat ketiga Pertandingan Audit Klinikal 2026 Hospital Bukit Mertajam
-Masuk Pertandingan Poster 12th International Congress of Asean Pacific Society of Infection Control(APSIC) pada 30 Julai-2 Aug 2026
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6AnaesthesiaClinical audit on the incidence and prevention of pressure ulcers in ICU patientsThis project was undertaken to improve staff adherence to best practices in pressure ulcer prevention and management by identifying gaps in current practice and implementing appropriate improvement strategiesSelesaiTempat ketiga Pertandingan Audit Klinikal 2025 peringkat Hospital Bukit Mertajam
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7EmergencyReducing blood culture contamination in emergency trauma department Hospital Bukit Mertajam
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8PaediatricClinical audit on compliance of antibiotics used in paediatric ward with the National Antibiotic Guideline 2024 ON-GOINGJan 2026MAC 202628/4/2026: Clinical Audit Workshop
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9Infection controlAudit on MDRO associated BSI in medical wads in Hospital Bukit MertajamThis project is aimed to reduce MDRO-associated BSI by ≥20% by improving aseptic IV Hub Access(Scrub the Hub)ON-GOINGJan 2026Sep 202628/4/2026: Clinical Audit Workshop Presented during Clinical Audit Competition HBM 2026
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10Psychiatry
MONITORING MATERS : Clinical Audit on Compliance with Annual Blood Investigations Review Among Patients Prescribed Psychotropic Medications in the Specialist Psychiatry Clinic, Hospital Bukit Mertajam
This audit aimed to assess compliance with annual blood investigations among patients prescribed psychotropic medications, based on NICE, Maudsley, and local CPG guidelines, and to identify areas for improvement.SELESAINovember 2025April 202628/4/2026: Clinical Audit Workshop
TEMPAT PERTAMA PERTANDINGAN AUDIT KLINIKAL 2026 PERINGKAT HOSP BUKIT MERTAJAM
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11Speech Therapy Optimization of Adult New Case Attendance via Telephone Verification This project is aimed to improve patient attendance rates and optimize the utilization of available clinician slots.ON-GOINGSeptember 2025March 202628/4/2026: Clinical Audit Workshop
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12Radiology Adequacy of Breathing Effort in High -Resolution Computed Tomography Thorax Examination High-Resolution CT (HRCT) Thorax- Essential for evaluating interstitial lung disease and small airway - - Requires adequate inspiratory and expiratory breath-hold
- Poor breathing effort may lead o:
- Reduced diagnostic confidence
- Misinterpretation of pathology
- Repeat scans and increase radiation exposure 		CompletedJuly 2025April 202628/4/2026: Clinical Audit WorkshopTempat kedua Pertandingan Audit Klinikal 2026 peringkat Hospital Bukit Mertajam
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13AnaesthesiaA Clinical Audit to Improve Compliance with Preventive Measures among Patients Infected with Multidrug-Resistant Organisms28/4/2026: Clinical Audit Workshop
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14Nursing Improving Patient Discharge Efficiency Through the Implementation of a Discharge Lounge: A Clinical Audit28/4/2026: Clinical Audit Workshop
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