Clinical Audit

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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 MFT 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.

Audit Title Directorate Date Closed
Post Dural Puncture Headache Management Anaesthesia 16/09/2017
Critical Care Safeguarding Assessment Critical Care (MRI) 24/07/2017
Respiratory Physiotherapy Documentation on PICU Allied Health Professionals 29/09/2017
Medicines Security and Storage Pharmacy 23/08/2017
Penicillin Allergy Laboratory Medicine 25/09/2017
Dataset Reporting of Cervical Loop Biopsies Laboratory Medicine 31/08/2017
Residual Anaesthetic Drugs in IV lines Anaesthesia 25/07/2017
Management of Pre-operative Hypertension Anaesthesia 29/09/2017
Block Selection in Cut-up by Biomedical Scientists Laboratory Medicine 24/08/2017
Community Stroke and ESD Services [NICE QS] Allied Health Professionals 28/09/2017
Medical Device Training Medical Engineering And Maintenance 29/08/2017
Pre-Operative Optimisation of Patients Refusing Blood Products (PRBPs) – Staff Knowledge Audit Anaesthesia 28/09/2017
Equality and Diversity Objective Audit Division-Wide 25/07/2017
Appropriate Labelling of Gynaecological Specimens Booked into the Adult Histopathology Department Under the “HSC205” Suspected Cancer Pathway Laboratory Medicine 20/07/2017
Expired Drugs in MRI theatres Anaesthesia 29/08/2017
Care of the Deceased Person (Adult) 2016 Trust-Wide 24/08/2017
VTE Audit Medical Directors Team 18/08/2017
Hydration Pathway Patient Services 23/08/2017
Periodontal referrals accuracy Dental Hospital 24/08/2017
Referrals with Associated Radiographs to the Orthodontic Department Dental Hospital 25/07/2017
Body Mass Index recording and appropriate dietetic referrals Dental Hospital 18/07/2017
A retrospective audit to assess the quality of record keeping within the paediatric department with regards to inhalation sedation Dental Hospital 17/08/2017
Fasting and Adverse Incidents under Sedation Dental Hospital 17/08/2017
Mental Capacity act and its use for dental patients Dental Hospital 24/08/2017
Oral Medicine Biopsy Pathway Dental Hospital 21/08/2017
Quality of periapical radiographic images taken in the Paediatric department Dental Hospital 24/08/2017
To assess the quality of lateral oblique jaw radiographs taken in the x-ray department Dental Hospital 20/07/2017
Audit of Use of Iluvien Against NICE Guidance Ophthalmology 06/09/2017
Paediatric Orbital Cellulitis Ophthalmology 25/07/2017
Posterior Artisan Lenses: Visual outcomes and Complications Ophthalmology 06/09/2017
History taking for newly referred patients with diabetic retinopathy Ophthalmology 13/07/2017
Photochemical corneal collagen cross linkage Ophthalmology 25/09/2017
Type and quality of referrals to Primary care/ comprehensive ophthalmology (PCC) Ophthalmology 26/07/2017
Compliance with guidelines for the assessment and management of the ocular features of MPS in children Ophthalmology 06/09/2017
Paediatric Ptosis Surgery Ophthalmology 10/08/2017
Hip Surveillance Pathway and 24 hour Postural Management Community Children’s Services 14/09/2017
Eye examinations within the Emergency Department Urgent Care 04/08/2017
Test Results Management (including clinically significant results) Community Adults And Specialist Services 30/08/2017
An audit of the quality of Autism Spectrum Disorder diagnostic reports Community Adults And Specialist Services 24/07/2017
Children’s Community Record Keeping Audit Community Children’s Services 17/08/2017
Trust Priority Falls Audit 2016/17 Division-Wide 23/08/2017
Cancer of Unknown Primary Service Adult Integrated Medicine 24/07/2017
Stroke and Transient Ischaemic attack Clinical Decision Support Guideline Audit Urgent Care 31/08/2017
A clinical audit of the investigation strategy of suspected malaria in the Manchester Royal Infection Emergency Department. Urgent Care 13/07/2017
Neutropenic Sepsis Adult Integrated Medicine 13/07/2017
Suspected pulmonary embolisms in pregnancy Urgent Care 29/08/2017
An audit of daily clinical documentation by medical staff in ward 15 clinical notes Adult Integrated Medicine 27/09/2017
Lone acute severe headache in the emergency department Urgent Care 17/08/2017
Patient Confidentiality in Medical Notes Research And Innovation 02/08/2017
Naso/oro-gastric jejunal tube placment : Knowledge and practice of childrens nurses Division-Wide 14/09/2017
Audit of High risk medication monitoring CAMHS 07/07/2017
Time to Diagnosis and Symptom Interval of CNS Tumours in Oncology Patients aged 5-16 years at RMCH: An Impact of HeadSmart Medicine 3 (RMCH) 24/07/2017
Availability of Paediatric Front of Neck Access Equipment Theatres & Anaesthesia (Childrens) 14/09/2017
Adequacy of Paediatric difficult airway equipment audit Theatres & Anaesthesia (Childrens) 14/09/2017
FP10 prescribing of Melatonin and Stimulant medication in Salford CAMHS CAMHS 24/07/2017
Cardiovascular Risk Factors in Juvenile SLE Medicine 2 (RMCH) 14/09/2017
Use of Microcuff endotracheal tubes in children Theatres & Anaesthesia (Childrens) 24/07/2017
Use of Home Oxygen in Children Medicine 2 (RMCH) 24/07/2017
Attention deficit Hyperactivity disorder assesssment at the Winnicott centre against NICE guidelines CAMHS 07/07/2017
Anaesthesia and Analgesia for delayed bladder exstrophy repair(DER); impact on level of postoperative care Theatres & Anaesthesia (Childrens) 07/07/2017
RMCH CF Annual Review Audit Medicine 2 (RMCH) 24/07/2017
CAMHS Clinical Case note Audit CAMHS 05/07/2017
Enteral nutritional guidelines on the PICU Critical Care (Childrens) 14/09/2017
Use of Omalizumab for treating severe persistent allergic asthma  at RMCH Respiratory Department Medicine 2 (RMCH) 14/09/2017
Skin Care and pressure ulcer prevention in the PICU Critical Care (Childrens) 24/07/2017
Management of sepsis  – NWTS transferred patient review over a 1 year period Critical Care (Childrens) 14/09/2017
Use of the ASQ-3 and ASQ:SE for parents attending the Manchester CAPS Baby Incredible Years Groups. CAMHS 16/08/2017
Paediatric Surgical Site Assessments Surgery 1 (RMCH) 21/09/2017
Anaesthesia outcomes for patients with Mucopolysaccharidoses type 6 ( Marateaux-Lamy syndrome) Theatres & Anaesthesia (Childrens) 14/09/2017
Accuracy of acute scrotum diagnosis in children Surgery 1 (RMCH) 15/09/2017
Eruption of canines into alveolar bone grafts in cleft lip and palate patients Surgery 1 (RMCH) 24/07/2017
Changing practice,  anorectal malformation and distal loopogram Surgery 1 (RMCH) 14/09/2017
Children’s early warning Score (EWS) Re-audit Division-Wide 07/07/2017
Pervasive Arousal WIthdrwal Syndrome Care Pathway Audit CAMHS 14/09/2017
Duration of anaesthesia for hernia repair in children less than 3 years of age. Theatres & Anaesthesia (Childrens) 24/07/2017
Paediatric Clinical Observation Re-Audit Division-Wide 14/09/2017
SSRI prescribing Practices in Salford CAMHS CAMHS 14/09/2017
Audit of HDU-level transfers referred to NWTS over 1 year Critical Care (Childrens) 14/09/2017
NWTS transfers for palliative/end of life care Critical Care (Childrens) 14/09/2017
Inhaled Nitric Oxide use at the North West and (NWTS) Critical Care (Childrens) 24/07/2017
The Assessment of Children with Autism Spectrum Disorder at The Winnicott Centre against NICE guidelines. CAMHS 14/09/2017
Medication Review Documentation July 2017 CAMHS 16/08/2017
An  Audit to Assess the Quality of Lateral Cephalometric Radiographs at the Cleft Lip and Palate Unit RMCH Surgery 1 (RMCH) 14/09/2017
Correction megaprepuce Surgery 1 (RMCH) 14/09/2017
The provision of post exposure Prophylaxis for HIV Outpatient Medical Specialities 18/08/2017
Standards in Anca test checking and follow-up Renal Medicine 08/08/2017
Fluid balance audit Renal Medicine 27/09/2017
Audit of timeliness of observations Manchester Heart Centre 02/08/2017
Impact of blood sampling on service delivery Haematology And Gastroenterology 29/09/2017
Management of hyperglycaemia and steroid therapy Outpatient Medical Specialities 26/09/2017
Echocardiogram performed before discharge in heart valve surgery Manchester Heart Centre 30/08/2017
Management of Primary HIV Infection Outpatient Medical Specialities 27/09/2017
Instrumental Delivery Obstetrics 21/07/2017
Peri-operative Anaglesia for Enhance Recovery Patients Undergoing Major Surgery Gynaecology 11/09/2017
Induction of labour Obstetrics 21/07/2017
Management of Gestational Hypertension and Mild Pre-eclampsia Obstetrics 21/07/2017
Intrauterine Fetal Blood Transfusion Obstetrics 21/07/2017
Management of Gestational diabetes at the Trafford Antenatal Clinic Obstetrics 21/07/2017
Immunisation Audit: Pre and Post Men B vaccination Newborn Intensive Care 25/07/2017
Counselling Services Response Times to Counselling Enquiries Sexual Assault Referral 30/08/2017
Neonatal Cranial Ultrasound Scans in SMH – Protocol and Practice Newborn Intensive Care 06/07/2017
Constitutional Copy Number Variants (CNVs) encompassing Cancer (Ca) predisposing gene(s) detected by Chromosomal Microarray (CMA) as an Incidental Finding Genomic Medicine 14/07/2017
Postnatal Venous Thromboembolism (VTE) Risk Assessment and appropriate thromboprophylaxis Obstetrics 21/07/2017
Management of ectopic pregnancy Gynaecology 25/07/2017
Post operative voiding/Bladder care management Gynaecology 30/08/2017
The impact of service reconfiguration on the provision of laparascopic cholecystectomy for patients admitted with acute gallstone disease. General Surgery 12/07/2017
NICE guidelines for pressure ulcers prevention and management Medicine & Rehabilitation 31/08/2017
Assess The Effectiveness Of Degludac Insulin Medicine & Rehabilitation 13/09/2017

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