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HealthMarch 08, 2021

Australia’s CoBRA tool and next generation clinical auditing

By: Sarah Handzel, BSN, RN
Clinical auditing to improve the quality of healthcare delivery has become deeply embedded in modern healthcare organizations.

The frequency of audits typically depends on the clinical area and specific organizational policies, but the goal is always the same—to identify circumstances that could lead to adverse events and determine how those events can best be avoided.

Quality and safety issues are important in healthcare organizations in terms of both clinical outcomes and patient satisfaction scores.1 Usually, audits are preplanned and generally have formal standards against which healthcare standards are measured.2 But many auditing processes are labor intensive, expensive, and time-consuming; also, they’re not usually completed at the point-of-care. Instead, audits occur after patient care is complete, which may compromise an auditor’s access to accurate and timely patient safety data.

In Western Australia, a major tertiary teaching hospital set out to streamline the clinical auditing process by developing the Combined Bedside and Risk Assessment (Cobra) online tool. The tool’s developmental methods, approach to auditing, and effectiveness are described in a new article in the Journal of Nursing Care Quality.3

Developing the Cobra tool

Nurse educators, clinical leaders, and other safety and quality clinicians worked together to develop the Cobra tool in accordance with the Australian Commission on Safety and Quality in Healthcare’s National Safety and Quality Health Service (NSQHS) Standards. These standards place special emphasis on:3

  • Blood management
  • Clinical governance
  • Communication for safety
  • Comprehensive care
  • Consumer engagement
  • Healthcare-associated infections
  • Medication safety
  • Recognizing and responding to clinical deterioration

The Cobra tool grew from existing audit tools that were deconstructed and remapped into a new clinical workflow format. After its initial release in 2016, the Cobra tool was revamped to include access to online cloud-based software to display auditing questions applicable to each patient’s clinical risk assessment and/or clinical setting.

Cobra tool audit questions are grouped by:

  • Bedside documentation review
  • Demographics
  • Medical record review of risks identified for each patient/consumer
  • Patient/consumer interviews, skin and device inspection, environmental safety scan of the bedside area

Cobra tool data collection

Within this particular hospital system, inpatient areas must complete a minimum of 20 Cobra audits each month. Thanks to the technology, each audit only takes approximately 10-15 minutes and can be completed at any time of day with minimal disruption to staffing levels.

Clinical staff members use portable electronic devices, including computers on wheels, to collect audit data directly at the bedside. The data collected is validated every 48 to 72 hours and is updated daily. This data is presented in the form of a digital dashboard, which delivers customizable live narrative reporting for all types of healthcare providers.

Security features include data encryption, personal identifiers, and passwords which are required to view any audit data. The results of each audit are ultimately stored in secure central servers designed to prevent unauthorized access.

Cobra’s clinical effectiveness

According to the article’s authors, Cobra has been used to create almost 18,000 patient clinical audits since 2016, in part because the tool has been integrated directly into routine workflows. Cobra represents a transformation in patient care since the tool allows for auditing while clinicians continually monitor patients’ safety risk at the bedside. This, in turn, allows for immediate remedial action whenever risks to patient safety are identified.

By using Cobra, clinical staff appear to be more engaged and proficient in quality improvement practices. The tool also helps to reinforce individual ownership and accountability for unit safety and patient care quality.

The article authors suggest that tools such as Cobra could be instrumental in the development of next generation auditing tools, especially since it provides a streamlined and efficient process. They conclude that future versions of Cobra will include greater consumer engagement for the development and refinement of assessment questions. Additionally, key performance indicators addressing future editions of NHSQS Standards could be included.

Sarah Handzel, BSN, RN
Freelance Health and Medical Content Writer, Wolters Kluwer Health
Sarah has over nine years’ experience in various clinical areas, including surgery, endocrinology, family practice, and pharmaceuticals. She began writing professionally in 2016 as a way to use her medical knowledge beyond the bedside to help educate and inform healthcare consumers and providers.
  1. Hut-Mossel, Lisanne, et al. “Understanding How and Why Audits Work: Protocol for a Realist Review of Audit Programmes to Improve Hospital Care.” BMJ Open, BMJ Publishing Group, 14 June 2017,
  2. Limb, Christopher MBBS, et al. How to Conduct a Clinical Audit and Quality Improvement... : IJS Oncology. International Journal of Surgery: Oncology, July 2017,
  3. Kidd, Heather PhD, RN, et al. “Developing the Next Generation in Electronic Clinical Auditing: CoBRA Tool.” NursingCenter, 2020,
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