Background/Objective: Hand hygiene is a cornerstone of infection prevention; however, compliance is inconsistent in intensive care units (ICUs), particularly in resource-constrained settings. This study evaluated whether a low-cost, multimodal quality improvement intervention could improve process-level hand hygiene compliance using routine, episode-based audits embedded in the ICU practice. Methods: We conducted a single-cycle Plan-Do-Study-Act quality improvement project in a 12-bed mixed medical–surgical ICU in Pakistan (December 2023–January 2024). Hand hygiene performance was assessed using the unit’s routine weekly episode-based audit protocol, aligned with the WHO Five Moments framework. A targeted multimodal intervention comprising education, point-of-care visual reminders, audit feedback, and leadership engagement was implemented between the pre- and post-intervention phases (four weeks each). Non-applicable moments were scored as “compliant by default” according to the institutional protocol. A sensitivity analysis was performed excluding these moments to calculate pure adherence. Compliance proportions were summarized using exact 95% Clopper–Pearson confidence intervals without inferential testing. Results: A total of 942 audit episodes (471 per phase) generated 4710 moment-level assessments were generated. Composite hand hygiene compliance increased from 63.1% pre-intervention to 82.0% post-intervention [absolute increase: 18.9 percentage points (pp)]. Sensitivity analysis excluding non-applicable moments demonstrated pure adherence improvement from 54.2% to 82.5% (+28.3 pp), confirming a genuine behavioral change rather than a measurement artifact. Compliance improved across all five WHO moments, with the largest gains in awareness-dependent moments targeted by the intervention: before touching the patient (+27.0 pp) and after touching patient surroundings (+40.0 pp). Week-by-week compliance remained stable within both phases, without immediate post-intervention decay. Conclusions: A pragmatic, low-cost multimodal intervention embedded in routine ICU workflows was associated with substantial short-term improvements in hand hygiene compliance over a four-week observation period, particularly for awareness-dependent behaviors. Episode-based audit systems can support directional process monitoring in resource-limited critical care settings without the need for electronic surveillance. However, its long-term sustainability beyond one month and generalizability to other settings remain unknown. Sensitivity analyses are essential when using “compliant by default” scoring to distinguish adherence patterns from measurement artifacts.

Background/Objectives: Accurate drug allergy documentation is essential for patient safety; however, documentation quality remains poor worldwide. In resource-limited settings that rely on paper records, allergy information may become fragmented across multiple forms, and evidence on concordance between paper-based documentation systems is limited. This audit assessed concordance between clinical notes and drug Kardex records, and completeness of drug allergy documentation entries, in a manual hospital system. Methods: This retrospective clinical audit, reported in accordance with SQUIRE 2.0 guidelines, examined 88 randomly selected patient records from 525 consecutive admissions to a general medicine ward in Pakistan during June–July 2024, retrospectively reviewed in August 2024. The audit assessed allergy status documentation in clinical notes and the drug Kardex, evaluated completeness against five internationally recommended elements (drug name, reaction description, severity, date, and treatment), and measured inter-system concordance using McNemar’s test and Cohen’s kappa. Results: Drug allergy status was documented in 25.0% of clinical notes (95% CI: 16.5–35.4%) versus 94.3% of drug Kardex records (95% CI: 87.2–98.1%), representing a 69.3 percentage-point gap (McNemar χ² = 59.06, p < 0.001). Inter-system agreement was poor (κ = 0.0079; 95% CI: −0.046 to 0.062), with an overall concordance of 28.4%. Discordant pairs showed that undocumented allergy status was far more likely in clinical notes than in the drug Kardex (OR = 62.00). Kardex-only documentation occurred in 62 of 88 patients (70.5%). Among nine patients with documented allergy history in at least one source, none met the five-element completeness standards (0%; 95% CI: 0.0–33.6%). Recorded entries were generic statements such as “drug allergy” or “allergic to antibiotics” without clinically actionable details. Conclusions: Drug allergy documentation showed two major quality failures: poor concordance between parallel paper records and lack of actionable detail in recorded entries. The two systems functioned independently rather than as complementary safety checks, with allergy information often present in the drug Kardex but absent from clinical notes. This Kardex-only failure mode may be a practical target for quality improvement through structured five-element templates, prompts for clinicians to review the drug Kardex, and interdisciplinary allergy-reconciliation workflows. These strategies require prospective evaluation in this setting.