Reports
A44
Centre ISEC Mid Valley Last month · 1 Sep – 30 Sep 2026
Safety and Quality Indicators
18| IOL lot recorded | OT manager | ASC | 0.0% | ≥ 100.0% | Not met | — · — · — · 0 · 0 · 0 | WHO checklist sign-out |
| Return to theatre within 30 days | Head of department | ASC | 2.6% | ≤ 1.0% | Not met | 4.4 · 4.5 · 5.3 · 3.2 · 2.6 · 0 | OT cases |
| Theatre cancellations | OT manager | ASC | 1.7% | ≤ 5.0% | Met | 1.7 · 1.1 · 1.4 · 1.8 · 1.7 · 1 | OT cases |
| Op notes signed | OT manager | ASC | — | ≥ 95.0% | Not captured | — · — · — · — · — · 88.9 | OT cases and op notes |
| Posterior capsule rupture | Head of department | Cataract | 0.0% | ≤ 2.0% | Met | 0 · 0 · 0 · 0 · 0 · 0 | Signed op notes |
| Endophthalmitis | Infection control | Cataract | 0.0 | ≤ 1.0 | Met | 0 · 0 · 0 · 0 · 0 · 0 | IPC cases |
| Post-op VA 6/12 or better | Head of department | Cataract | 94.0% | ≥ 85.0% | Met | 88.8 · 92.1 · 88.3 · 89.9 · 94 · 100 | Eye record visits |
| Within ±0.5 D of target refraction | Head of department | Cataract | 70.3% | ≥ 60.0% | Met | 70.5 · 71.9 · 70.3 · 72.1 · 70.3 · 50 | Eye record outcome (target and post-op SE) |
| WHO safety checklist complete | OT manager | IPSG.4 | 76.8% | ≥ 100.0% | Not met | 81.7 · 81.7 · 81.2 · 79.6 · 76.8 · 83.6 | OT safety checklist |
| Site marking confirmed | OT manager | IPSG.4 | 0.0% | ≥ 100.0% | Not met | — · — · — · 0 · 0 · 0 | WHO checklist sign-in |
| Medication incidents reported | Chief pharmacist | MMU | 0 | — | No target | 0 · 1 · 0 · 1 · 0 · 1 | Incidents |
| Hand hygiene compliance | Infection control | PCI | — | ≥ 90.0% | No data | — · — · — · — · — · 89.4 | Hand hygiene audits |
| Sterilisation indicator failures | CSSD | PCI | 0 | ≤ 0 | Met | 0 · 0 · 0 · 0 · 0 · 0 | Incidents |
| Endophthalmitis after injection | Infection control | PCI | — | ≤ 1.0 | No data | — · — · — · — · — · 0 | IPC cases and the theatre injection list |
| Complaints received | Patient relations | PFR | 0 | — | No target | 0 · 0 · 0 · 0 · 0 · 0 | Complaints |
| Incidents closed by the due date | Quality officer | QPS | 100.0% | ≥ 90.0% | Met | 100 · 100 · 100 · 100 · 100 · 100 | Incidents |
| Sentinel events | Quality officer | QPS | 0 | ≤ 0 | Met | 0 · 0 · 0 · 0 · 0 · 0 | Incidents |
| CAPA effective at the check | Quality officer | QPS | — | ≥ 80.0% | No data | — · — · — · — · — · — | Incidents |