Clinical Audit Report: Enhancing Compliance with Pediatric Emergency Care Standards for Safer, Smart-er Practice

Maysoon Fadel Elseed¹, Nojoud Elsayid¹, Samah Mahmoud¹, Azza Mohammed¹, Eman Abaker¹, Sahar Elawad¹

Abstract

This hospital-wide audit was conducted to assess the hospital's adherence to key clinical, administrative, and ethical standards. It used global benchmarks from the Ministry of Health (MOH), Joint Commission International (JCI), World Health Organization (WHO), and the Occupational Safety and Health Administration (OSHA). A mixed-methods approach was used across five main areas: medical documentation, policy compliance, staff feedback, real-time clinical observation, and comparison with international standards. Data were collected from 45 patient records and 45 healthcare workers, encompassing over 200 compliance indicators.

The findings revealed a notable discrepancy between the hospital's performance in emergency care and its management of everyday operations. There were high compliance rates in areas such as medication safety (86.7%), emergency preparedness (77.8%), and the use of PPE (75.6%), indicating that the hospital is well-prepared for high-risk situations. However, basic practices were lacking: only 48.9% of records contained correct patient demographic information, only 55.6% had proper documentation for the medication given, and just 24.4% followed the rules for reporting adverse events and obtaining patient consent. Additionally, 71.1% of staff reported being afraid to report safety problems, and only 44.4% received regular training. Statistical analysis supported this, showing widespread issues with documentation (χ² = 16.05, p = 0.066) and significant differences in how policies are enforced (χ² = 85.89, p < 0.000001), with better compliance in areas that are more closely monitored.

The audit reveals that the hospital tends to prioritize what is visible to outside reviewers but falls short in everyday safety and ethical practices. To address this, the report recommends five key improvements: enhanced documentation, stricter enforcement of policies that are often overlooked, establishing a safe environment for staff to report issues, more comprehensive training, and developing a system for mitigating risks before problems arise. If these changes are not made, the hospital could face accreditation problems, legal risks, and harm to patient safety. This audit makes it clear that the hospital must move from a reactive approach to one that focuses on ongoing, organization-wide quality improvement.