Episodes reviewed
24
Overall compliance
89.7%
Target ≥ 90%
Safety concerns identified
5
Escalate through local incident processes.
Results
Across 24 episodes, overall compliance against the 28 audit criteria was 89.7% against a local target of 90%. 20 criteria met their local standard and 8 fell below it. Investigations completed within the locally expected timeframe: 33.3%. Results reviewed within the locally expected timeframe: 70.8%. Results actioned within the locally expected timeframe: 79.2%. The most frequently recorded primary reason for delay was "No reason documented" (7 episodes). Estimated bed days affected by investigation delay: 46.
Interpretation
the weakest area is "Investigation was performed or sample was taken within the locally expected timeframe." at 33.3%. The strongest area is "Clinical indication for the investigation was documented." at 100%. Variation between wards, departments and specialties suggests differences in requesting practice, escalation routes and results acknowledgement rather than clinician knowledge alone.
Areas of good practice
Criteria meeting the local standard.
- 100%Clinical indication for the investigation was documented.
- 100%Delay stage was identifiable from the record.
- 100%Criteria-to-reside or discharge readiness impact was documented where relevant.
- 100%Impact on diagnosis was documented or inferable.
- 100%Impact on treatment decision was documented or inferable.
Key gaps identified
Criteria below the local standard.
- Investigation was performed or sample was taken within the locally expected timeframe.Compliance 33.3% against a local standard of 90% (8 yes, 16 no, 0 excluded).
- Outpatient, ambulatory, planned return or community diagnostic option was considered where the patient was otherwise discharge ready and this was safe.Compliance 36.4% against a local standard of 90% (4 yes, 7 no, 13 excluded).
- Investigation delay was escalated according to local policy where escalation criteria were met.Compliance 65.2% against a local standard of 90% (15 yes, 8 no, 1 excluded).
- Investigation was requested within the locally expected timeframe after it became clinically indicated.Compliance 75% against a local standard of 90% (18 yes, 6 no, 0 excluded).
- Result was reviewed by the clinical team within the locally expected timeframe.Compliance 79.2% against a local standard of 90% (19 yes, 5 no, 0 excluded).
- Alternative investigation or pathway was considered where appropriate.Compliance 87.5% against a local standard of 90% (21 yes, 3 no, 0 excluded).
Governance implications
Investigation delays with documented impact on discharge readiness or length of stay should be reported through local patient flow and governance routes.
5 episode(s) recorded a safety concern. Confirm each has been reported and reviewed under local incident reporting policy.
Limitations
Retrospective record review depends on the quality of contemporaneous documentation. Delay durations reconstructed from system timestamps may not reflect clinical decision points. Impact categories rely on reviewer judgement. Add local context here.
Clinical safety note
This tool supports local audit, quality improvement and operational governance review. It does not replace clinical judgement, diagnostic pathways, escalation policies, radiology protocols, pathology protocols, specialist advice, discharge policy, criteria-to-reside review, emergency pathways or incident reporting. Any clinical deterioration, missed abnormal result, suspected serious diagnosis, unsafe discharge concern, delayed cancer or time-critical investigation concern, communication failure or patient safety concern must be escalated according to local policy. Do not enter patient names, NHS numbers, hospital numbers, full dates of birth, addresses or other direct identifiers.