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Common NABH Accreditation Failures: 15 Mistakes to Avoid

February 1, 2026 14 min read

Many hospitals invest months of effort and lakhs of rupees into NABH accreditation—only to receive non-conformities that delay or block approval. Learn from these 15 common failures to ensure your hospital passes on the first attempt.

Important: Non-Conformities Can Be Fatal

NABH assessors classify issues as Major Non-Conformity (NC) or Minor NC. Too many Major NCs = failed assessment. Even minor NCs require corrective action within 90 days.

The 15 Most Common Failures

1

Incomplete Documentation

Problem:

Policies exist but are not signed, dated, or approved by management.

Solution:

Ensure all documents have version control, approval signatures, and review dates.

2

Staff Not Aware of Policies

Problem:

Documents exist but staff haven't read or been trained on them.

Solution:

Conduct regular training sessions and keep signed acknowledgment records.

3

Inconsistent Medical Records

Problem:

Patient files missing forms, incomplete entries, or illegible handwriting.

Solution:

Use digital EMR with mandatory fields. Regular medical records audits.

4

Poor Infection Control Practices

Problem:

Hand hygiene compliance below 80%, improper biomedical waste segregation.

Solution:

Install hand hygiene stations, conduct audits, display color-coded waste bins.

5

Medication Errors Not Reported

Problem:

Near-misses and errors go unreported due to fear of blame.

Solution:

Create blame-free reporting culture. Track and analyze all incidents.

6

Equipment Maintenance Gaps

Problem:

Critical equipment not calibrated or maintained on schedule.

Solution:

Maintain equipment logs with preventive maintenance schedules.

7

Consent Process Flaws

Problem:

Consents not in patient's language, not explaining risks, or taken after procedure.

Solution:

Use standardized consent forms in regional languages. Train staff on consent process.

8

Fire Safety Non-Compliance

Problem:

Expired fire extinguishers, blocked exits, no fire drills conducted.

Solution:

Quarterly fire drills, monthly equipment checks, clear exit signage.

9

Quality Indicators Not Tracked

Problem:

NABH-mandated indicators not measured or analyzed monthly.

Solution:

Set up dashboards for key indicators. Monthly trend analysis required.

10

Credentialing Incomplete

Problem:

Doctor files missing degree verification, registration certificates, or privileges.

Solution:

Complete credentialing files for all medical staff before assessment.

11

Patient Rights Not Displayed

Problem:

Patient rights charter not visible in admission area and wards.

Solution:

Display patient rights in local languages at admission and each ward.

12

Emergency Drugs Expired

Problem:

Crash cart drugs expired or missing during mock drills.

Solution:

Daily crash cart checks with documented checklists.

13

No Internal Audits

Problem:

Hospital hasn't conducted internal audits before assessment.

Solution:

Conduct internal audits 3-6 months before NABH assessment.

14

Surgical Safety Violations

Problem:

Time-out procedures not followed, surgical site not marked.

Solution:

Implement WHO Surgical Safety Checklist for every procedure.

15

Staff Files Incomplete

Problem:

Missing health checkups, training records, or job descriptions.

Solution:

Complete HR files with all required documents for every staff member.

Pre-Assessment Checklist

Before the NABH assessment, ensure you've addressed these areas:

  • ✅ All documents approved and version-controlled
  • ✅ Staff trained and can answer questions about policies
  • ✅ Internal audit completed with CAPA closed
  • ✅ Quality indicators measured for at least 6 months
  • ✅ All medical staff credentialing complete
  • ✅ Fire and disaster mock drills conducted
  • ✅ Equipment maintenance up to date
  • ✅ Medical records audit shows >90% compliance

How Software Prevents Failures

Many NABH failures stem from manual processes. NABH-compliant hospital software prevents these issues:

  • Complete EMR: No missing fields, legible records, audit trails
  • Auto-Generated Consents: Proper consent workflow enforcement
  • Quality Dashboards: Real-time indicator tracking
  • Expiry Alerts: Drug and equipment expiry notifications
  • Training Tracking: Staff training records maintained automatically

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