overview of malaysian patient safety goals orientation program duchess of kent hospital dr paul chan...
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Overview of Malaysian Patient Safety Goals
Orientation Program Duchess of Kent Hospital
Dr Paul ChanAdv Dip (Med Sci), MBBS, MBA (Healthcare Management)
Deputy Director HDOK
30TH August 2012
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.
29th December 2013
30TH August 2012
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
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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 hospitals4 goals and 6 PIs – for clinics
9th December 2013
Malaysian Patient Safety Goals
1) To implement Clinical Governance
2) To implement WHO’s 1st Global Patient Safety Challenge: “Clean Care is Safer Care”
3) To implement WHO’s 2nd Global Patient Safety Challenge: “Safe Surgery Saves Lives”
4) To implement WHO’s 3rd Global Patient Safety Challenge: “Tackling Antimicrobial Resistance”
5) To improve the accuracy of patient identification
6) To ensure the safety of transfusions of blood and blood products
7) To improve medication safety
8) To improve clinical communication by implementing a critical test and critical value program
9) To reduce patient fall10)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 59th December 2013
30TH August 2012
Clinical Governance Framework
Clinical Governance
Accountable
High Standards of
Care
Excellence in Clinical Care
Continuous Improvement
of Service Quality
NHSSource : UK NHS9th December 2013
30TH August 2012
Goal, Indicator & Target
Goal no
Goal Indicator Target
1 To implement Clinical Governance
Implementation of Clinical Governance
Clinical Governance implemented
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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
30TH August 2012
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
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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
zero
99th December 2013
30TH August 2012
Goal no Goal Indicators Target4 To implement
WHO’s 3rd Global Patient Safety Challenge: “Tackling Antimicrobial Resistance”
Incidence rate ofMRSA infection
≤ 0.4% /month
Incidence rate ofESBL – Klebsiella pneumoniae
≤ 0.3%/month
Incidence rate ofESBL-E.coli infection
≤ 0.2%/ month
109th December 2013
30TH August 2012
Goal no
Goal Indicator Target
5 To improve the accuracy of patient identification
Compliance rate of at least 2 identifiers implemented
100%
119th December 2013
30TH August 2012
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
-
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Transfusion error (actual): wrong pack of blood or its product is given for the patientTransfusion error (near miss): transfusion error that almost occur but prevented/ intervened resulting in no harm 9th December 2013
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30TH August 2012
Goal no Goal Indicators Target
7 To improve medication safety
1. No of medication error (actual)
Zero
2. No of medication error (near miss)
-
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• 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
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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%
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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
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List of Critical Test - Haematology
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List of Critical Test – Chemical Pathology
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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)
10% reduction per year based on
previous year’s data as a baseline
189th December 2013
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Goal no Goal Indicator Target
10 To reduce the incidence of healthcare-associated pressure ulcer
Incidence rate of pressure ulcer
≤ 3 %
199th December 2013
30TH August 2012
Goal no Goal Indicator Target
11 To reduce Catheter-Related Bloodstream Infection (CRBSI)
Rate of CRBSI <5 per 1000 catheter days
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Central Venous Catheter Care Bundle (CVC-CB)It consists of five evidence-based procedures recommended by CDC (Center of Disease Control and Prevention)
1. Hand hygiene2. Maximal barrier precautions upon insertion3. Chlorhexidine skin antisepsis4. Optimal catheter site selection, with subclavian
vein as the preferred site for non-tunneled catheters
5. Daily review of line necessity with prompt removal of unnecessary line
9th December 2013
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Goal no Goal Indicator Target
12 To reduce Ventilator Associated Pneumonia (VAP)
Rate of VAP <10 per 1000 ventilator days
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The ventilator care bundle has four key components:1. Elevation of head of the bed to between 30- 45 degrees2. Daily sedation vacation3. Peptic ulcer disease prophylaxis4. Deep venous thrombosis prophylaxis unless contraindicated
*VAP: Ventilator Associated Pneumonia: Pneumonia that occurs after 48 hours of intubation
9th December 2013
30TH August 2012
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
229th December 2013
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
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