Dr. Md. Shakir

Patient Safety Management

• Coordinate implementation and monitoring of the hospital's patient safety program in accordance with NABH requirements.
• Identify potential patient-safety risks across clinical and non-clinical departments.
• Monitor safety practices and ensure timely reporting and escalation of safety concerns.
• Promote a proactive patient safety culture among doctors, nurses, technicians, administrative personnel, and support staff.
• Monitor compliance with hospital policies, protocols, SOPs, and patient safety practices.
• Conduct regular rounds to identify unsafe practices, environmental risks, documentation gaps, and process deviations.
• Coordinate corrective actions with concerned department heads.

Incident & Near-Miss Management

• Maintain and monitor the hospital's incident, adverse event, and near-miss reporting system.
• Encourage staff to report incidents and near misses in a non-punitive and learning-focused environment.
• Analyze reported incidents to identify trends, contributing factors, and areas requiring intervention.
• Coordinate Root Cause Analysis (RCA) for significant adverse events and serious incidents.
• Develop and monitor Corrective and Preventive Action (CAPA) plans.
• Follow up on CAPA implementation and assess effectiveness.
• Prepare incident-related reports for quality and management review meetings.

NABH Compliance

• Support implementation and monitoring of applicable NABH standards related to patient safety and quality.
• Maintain required policies, SOPs, formats, registers, checklists, and quality records.
• Coordinate departmental audits and compliance monitoring.
• Assist during NABH surveillance/reassessment and other external assessments.
• Identify non-conformities and coordinate timely corrective action.
• Monitor departmental compliance through regular audits and quality rounds.
• Maintain evidence and documentation required for NABH assessment.

Quality Indicators & Monitoring

• Monitor hospital-defined quality and patient safety indicators.
• Collect, analyze, and present quality data to management and quality committees.
• Identify trends and areas of improvement.
• Prepare monthly/quarterly quality reports as required.
• Support departmental teams in developing improvement plans.
• Monitor effectiveness of quality improvement initiatives.

Medication Safety

• Coordinate medication-safety initiatives in collaboration with doctors, nursing, and pharmacy teams.
• Monitor compliance with medication administration and documentation protocols.
• Support monitoring of medication errors, adverse drug events, and near misses.
• Promote safe practices related to high-alert and look-alike/sound-alike medications.
• Ensure appropriate reporting, analysis, and corrective action for medication-related incidents.

Patient Identification & Clinical Safety

• Monitor compliance with correct patient identification procedures.
• Ensure implementation of appropriate patient identification protocols before medication, investigations, procedures, blood transfusion, and other interventions.
• Monitor compliance with informed consent and patient-rights requirements.
• Promote safe communication and handover practices.
• Support implementation of clinical safety checklists.

Surgical & Procedural Safety

• Monitor compliance with applicable surgical safety and procedural safety protocols.
• Support implementation of pre-procedure verification, site marking, patient identification, and appropriate checklist processes.
• Coordinate audits related to OT and procedural safety.
• Identify gaps and facilitate corrective actions with clinical departments.

Falls & Pressure Injury Prevention

• Monitor compliance with patient-fall risk assessment and prevention protocols.
• Review fall incidents and coordinate RCA/CAPA where required.
• Monitor preventive measures for high-risk patients.
• Support implementation of pressure-injury prevention and monitoring systems.

Infection Prevention & Control

• Coordinate with the Infection Control Team to monitor patient safety practices.
• Support compliance with hand hygiene, PPE, sterilization, disinfection, biomedical waste management, and infection-prevention protocols.
• Participate in infection-control audits and awareness programs.
• Monitor compliance gaps and follow up on corrective actions.

Patient Rights & Experience

• Promote awareness of patient rights and responsibilities among patients, attendants, and staff.
• Monitor patient complaints, grievances, and feedback.
• Coordinate investigation and resolution of patient-safety-related complaints.
• Support initiatives aimed at improving patient experience and satisfaction.
• Ensure appropriate documentation of grievances and corrective actions.

Staff Training & Awareness

• Conduct or coordinate regular training programs on:
  • Patient safety
  • NABH standards
  • Incident reporting
  • RCA & CAPA
  • Hand hygiene
  • Medication safety
  • Patient identification
  • Fire safety
  • Emergency preparedness
  • Biomedical waste management
  • Infection prevention
  • Patient rights
  • Documentation and consent
• Maintain training records and competency documentation.

QUALITY & PATIENT SAFETY AUDITS

Regularly participate in / coordinate audits related to:

• Patient Identification
• Medication Safety
• Nursing Documentation
• Consent Documentation
• Medical Records
• Hand Hygiene
• Infection Control
• OT Safety
• Emergency Services
• ICU Safety
• Fall Prevention
• Pressure Injury Prevention
• Biomedical Waste Management
• Fire & Life Safety
• Crash Cart Readiness
• Emergency Equipment
• Blood Transfusion Safety
• Discharge Documentation
• Patient Rights
• Housekeeping & Environmental Safety

KEY RESPONSIBILITIES

Risk Management

• Identify potential hazards and patient-safety risks.
• Maintain risk registers where applicable.
• Monitor high-risk processes.
• Escalate critical safety concerns to appropriate authorities.
• Support implementation of preventive strategies.

Documentation

• Maintain patient safety records and reports.
• Maintain incident and near-miss documentation.
• Prepare audit reports and CAPA records.
• Maintain quality meeting documentation.
• Ensure availability of evidence for NABH compliance.

Quality Improvement

• Identify improvement opportunities through audits and data analysis.
• Support departmental quality-improvement projects.
• Monitor implementation and effectiveness of interventions.
• Promote continuous improvement across hospital departments.