1. Adv Dip (Med Sci), MBBS, MBA (Healthcare Management)
Overview of Malaysian Patient Safety Goals Orientation Program Duchess of Kent Hospital
Dr Paul Chan
Adv Dip (Med Sci), MBBS, MBA (Healthcare Management)
Deputy Director HDOK

2. Introduction The Malaysian Patient Safety Goals are designed :
To stimulate health care organizations in improving patient safety .
To outline important patient safety areas that need to be improved
To act as a “Performance Measurement” in areas that are critical to a safe health care system.
For Patient Safety Council to monitor and evaluate the status of patient safety in the country.
9th December 2013

3. Introduction Philosophy of Patient Safety Goals
“Patient safety shall be given prime importance in health care and preventable adverse events should be avoided at all costs”.
Scope:
Applicable to all public and private health care facilities
Hospitals, medical clinics, dental clinics
9th December 2013

4. Derivation of Goals, Indicators & Targets
Goals originally based on WHO Patient Safety Program Areas and JCI Patient Safety Goals
PIs and targets are based on:
Philosophy of goals, current MOH standards, statistics on previous performance of Malaysian health care facilities and consensus decision of Patient Safety Council Members, Officers from State Health Departments, Hospital Directors, Clinicians and discussion with Sir Liam Donaldson (Patient Safety Advisor to WHO Director General)
Initially there were 15 goals, 59 PIs which were reduced to 29 PIs after first meeting and further reduced to:
13 goals and 19 PIs – for hospitals
4 goals and 6 PIs – for clinics
9th December 2013

5. Malaysian Patient Safety Goals
To implement Clinical Governance
To implement WHO’s 1st Global Patient Safety Challenge: “Clean Care is Safer Care”
To implement WHO’s 2nd Global Patient Safety Challenge: “Safe Surgery Saves Lives”
To implement WHO’s 3rd Global Patient Safety Challenge: “Tackling Antimicrobial Resistance”
To improve the accuracy of patient identification
To ensure the safety of transfusions of blood and blood products
To improve medication safety
8) To improve clinical communication by implementing a critical test and critical value program
9) To reduce patient fall
10)To reduce the incidence of healthcare- associated pressure ulcer
11) To reduce Catheter-Related Bloodstream Infection (CRBSI)
12) To reduce Ventilator Associated Pneumonia (VAP)
13) To implement the Patient Safety Incident Reporting and Learning System
9th December 2013

6. Clinical Governance Framework
Accountable
High Standards of Care
Excellence in Clinical Care
Continuous Improvement of Service Quality
9th December 2013
Source : UK NHS

7. Goal, Indicator & Target
Goal no
Goal
Indicator
Target 1
To implement Clinical Governance
Implementation of Clinical Governance
Clinical Governance implemented
Clinical governance
A framework through which organisations are accountable for continually improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence will flourish.
Corporate accountability for clinical performance
Compliance to Clinical Governance can be evaluated using “Clinical Governance Assessment Tool” available in “Guideline on Achieving Excellence in Clinical Governance” produced by Patient Safety Council Malaysia & MOH
9th December 2013

8. Goal, Indicator & Target
Goal no
Goal
Indicator
Target 2
To implement WHO’s 1st Global Patient Safety Challenge: “Clean Care is Safer Care”
Hand hygiene compliance rate
≥ 75% at each audit
9th December 2013

9. 1. Number of wrong surgery performed zero
Goal no
Goal
Indicators
Target 3
To implement WHO’s 2nd Global Patient Safety Challenge: “Safe Surgery Saves Lives”
1. Number of wrong surgery performed
zero
2. Number of retained foreign body
9th December 2013

10. ESBL – Klebsiella pneumoniae ≤ 0.3%/month
Goal no
Goal
Indicators
Target 4
To implement WHO’s 3rd Global Patient Safety Challenge: “Tackling Antimicrobial Resistance”
Incidence rate of
MRSA infection
≤ 0.4% /month
ESBL – Klebsiella pneumoniae
≤ 0.3%/month
ESBL-E.coli infection
≤ 0.2%/ month
9th December 2013

11. To improve the accuracy of patient identification
Goal no
Goal
Indicator
Target 5
To improve the accuracy of patient identification
Compliance rate of at least 2 identifiers implemented
100%
9th December 2013

12. To ensure the safety of blood and blood products
Goal no
Goal
Indicators
Target 6
To ensure the safety of blood and blood products
No of transfusion error (actual)
Zero
No of ‘near misses’ during the transfusion process -
Transfusion error (actual): wrong pack of blood or its product is given for the patient
Transfusion error (near miss): transfusion error that almost occur but prevented/ intervened resulting in no harm
9th December 2013

14. To improve medication safety 1. No of medication error (actual) Zero
Goal no
Goal
Indicators
Target 7
To improve medication safety
1. No of medication error (actual)
Zero
2. No of medication error (near miss) -
Type of Medication error - Prescribing error, Omission error, Wrong time error, unauthorized drug error, Dose error, Dosage form error, Drug preparation error , Route of administration error, Administration Technique error, Deteriorated drug error, Monitoring error, Compliance error
Medication error (actual) – An error occurred and reached the patient
Medication error (near miss) - An error occurred but the error did not reach the patient, managed to be intervened
9th December 2013

15. % of critical value notified within 30 minutes 100%
Goal no
Goal
Indicator
Target 8
To improve clinical communication by implementing a critical test and critical value program
% of critical value notified within 30 minutes
100%
Definitions
Critical test: test which requires rapid communication of result.
Critical value: unexpected result that fall significantly outside the normal range and has the potential for serious adverse outcome to the patient if not dealt with promptly.
Criteria
Inclusion: critical list provided by hospital
(chemical pathology/ hematology tests)
9th December 2013

16. List of Critical Test - Haematology
9th December 2013

17. List of Critical Test – Chemical Pathology
9th December 2013

18. 10% reduction per year based on previous year’s data as a baseline
Goal no
Goal
Indicators
Target 9
To reduce patient fall
1. Number of fall (adult)
10% reduction per year based on previous year’s data as a baseline
2. Number of fall (pediatrics)
9th December 2013

19. To reduce the incidence of healthcare-associated pressure ulcer
Goal no
Goal
Indicator
Target 10
To reduce the incidence of healthcare-associated pressure ulcer
Incidence rate of pressure ulcer
≤ 3 %
9th December 2013

20. To reduce Catheter-Related Bloodstream Infection (CRBSI) Rate of CRBSI
Goal no
Goal
Indicator
Target 11
To reduce Catheter-Related Bloodstream Infection (CRBSI)
Rate of CRBSI
<5 per 1000 catheter days
Central Venous Catheter Care Bundle (CVC-CB)
It consists of five evidence-based procedures recommended by CDC (Center of Disease Control and Prevention)
Hand hygiene
Maximal barrier precautions upon insertion
Chlorhexidine skin antisepsis
Optimal catheter site selection, with subclavian vein as the preferred site for non-tunneled catheters
Daily review of line necessity with prompt removal of unnecessary line
9th December 2013

21. To reduce Ventilator Associated
Goal no
Goal
Indicator
Target 12
To reduce Ventilator Associated
Pneumonia (VAP)
Rate of VAP
<10 per 1000 ventilator days
*VAP: Ventilator Associated Pneumonia: Pneumonia that occurs after 48 hours of intubation
The ventilator care bundle has four key components:
Elevation of head of the bed to between degrees
Daily sedation vacation
Peptic ulcer disease prophylaxis
Deep venous thrombosis prophylaxis unless contraindicated
9th December 2013

22. To implement the Patient Safety Incident Reporting and Learning System
Goal no
Goal
Indicator/s
Target 13
To implement the Patient Safety Incident Reporting and Learning System
Implementing of Incident Reporting system (including RCA) or other methods to investigate the incidents (e.g clinical audit)
System implemented
9th December 2013

24. SUMMARY
Malaysian Patient Safety Goals is ready for implementation nation wide this year June 2013
Need to know what to do to ensure patients safety
Prevent litigation