Miranda Day Surgery


Phone: +61 2 9525 8669

Safety & Quality

It is our mission at Miranda Day Surgery (MDS) to provide high quality patient care. Reporting safety and quality data allows us to continually monitor our care delivery.

  2017 2018 2019
Certification (ISO 9001:2008 & NSQHS) YES YES YES
Infection Rate 0% 0% 0%
Hand Hygiene Compliance 92.3% 85% 86%
Patient Falls 0% 0% 0%
Unplanned Return to Theatre 0% 0% 0%
Unplanned Transfer to another hospital 0% 0% 0%
Medication Safety Errors 0% 0% 0%
Patients Developing Pressure Injuries 0% 0% 0%
Patient Satisfaction 95% 95% 98%

Below is a description of how we address each of these areas of quality


MDS is also fully accredited against the National Safety and Quality Health Service (NSQHS) Standards. Accreditation is assessed and granted by DNVGL, a certification bod approved by the Australian Commission for Safety and Quality Care.

Infection Rate

MDS implements systems to prevent and manage healthcare associated infection (HAI).

It is the belief of Miranda Day Surgery that through education of staff and patients, and monitoring of processes and systems as well as surveillance of any infection occurring as a result of care provided by the facility, the risk of transmission of HAI will be minimised.

To date these processes and systems have ensured that there have been no instances of HAI.

One of the most effective means to prevent infection spreading amongst patients is for all health professionals to wash their hands

Hand Hygiene

Hand hygiene is the single most important action in preventing the spread of infection in a health care setting.

All staff at Miranda Day Surgery carry out the 5 moments in hand hygiene at all required times.

Patients and visitors will also be encouraged to carry out appropriate hand hygiene through the use of alcohol based rubs located throughout our facility.

MDS participates in regular hand hygiene audits and results of these audits are relayed to the relevant internal committees.

Patient Falls

MDS implements systems to prevent patient falls and to minimise the harm from falls. Systems are in place to prevent patient falls including patient screening and assessment.

Click on this lionk to find useful information on fall prevention. Stay Safe at home, Prevent a fall.pdf

Medication Safety Errors

Medicines are commonly used to treat a variety of conditions in healthcare setting and therefore it is important to measure the risks of errors.

MDS has medication administration policies and processes in place which have been developed using best practice principles.

Medication errors are taken very seriously and staff are encouraged to report any incident regardless of how minor it might be.

Any medication incident are investigate and actioned through our Medical Advisory Committee.

Unplanned return to theatre

Unplanned returns to the operating theatre are frequently due to complication, for example to treat bleeding or other problems occurring early after the operation.

MDS monitors any unplanned theatre return. This data is used to determine if any action is required.

Unplanned Transfer to Hospital

MDS monitors and reports on any unplanned transfer to hospital.

No planned admission is expected to result in a transfer of a patient to an overnight facility therefore we monitor this to identify reasons why this occurred.

Patients Developing Pressure Injuries

Pressure injuries are wounds which form because of prolonged pressure to an area of skin. Pressure injuries are recognised worldwide as a common cause of harm to patients and could cause significant pain and discomfort which may result in a slower recovery for the patient.

While patients are only at MDS for a maximum of 4 hours, we use risk assessment tools to manage patients who may be at risk of pressure injuries.

Staff take every action to reduce the likelihood of a pressure injury occurring whilst in our facility.

Click on the link for more information on pressure injury prevention. Pressure Injury Prevention Information for Patients and Families

Patient Satisfaction

MDS believes in a patient centred care philosophy. All staff believe that care delivery should be respectful of and responsive to, the values, needs and preferences’ of its patients and their carers.

We encourage feedback from patients and their carers through our patient satisfaction surveys and post operative phone calls and on the day of surgery through our staff.

Information obtained is used to improve our care delivery.

Tips for Safe Healthcare

Click here to download Top Tips for Safe Health Care


Delirium is a medicalproblem which can develop when people are acutely unwell and/or are undergoing medical treatment, such as surgery. Older people especially those who have dementia, are more at risk of developing delirium at these times. Deliriun is also common after some anaesthetics. Although the cause is not always known, it is always a consequence of physical changes related to illness or its treatment (eg. infection, pain and the additional of medication)

Delirium causes changes to the person's usual mental functioning. its onset is rapid (hours or days). It is sometimes confused with other conditions (e.g. stroke, depression and dementia).

Delirium is a serious condition and, if not managed promptly, other complications can occur, such as falls, longer hospital stays and ongoing cognitive impairment. While delirium usually lasts only a few days and can be reverse, delirium sometimes persists even after the underlying problems are treated.

more information can be found in this Brochure - Click this link