Page 12 - Buletin Quality 2018
P. 12

MALAYSIAN PATIENT SAFETY GOALS (MPSG)

               Patient  safety  is  a  key  dimension  of  quality  in  health  care  and
          should be given prime importance by the healthcare fraternity. If possible,
          preventable adverse events should be avoided, at all cost. There are 13
          patient safety goals monitored to in HPP.

           NO     GOALS          KPI          TARGET     FREQUENCY    RESULT
                To implement   Implementation of   Clinical Governance
           1      Clinical   Clinical Governance       Implemented   Yearly                 Yes
                 Governance
                To implement the                                    Jan-Mac = 77%
                        st
                WHO’s 1   global                                    Apr-Jun = 70%
                                                                    Jul-Sep = 81%
           2     patient safety   Hand Hygiene   ≥75% compliance   Quarterly audit   Oct-Dec = 82%
                  challenge :                         rate at each audit
                             Compliance Rate
                “Clean Care is                                        *Only Apr- Jun
                 Safer Care”                                         not achieved
                To implement the   No. of “Wrong   Zero (0) cases   Monthly   Zero (0) cases
                      nd
                WHO’s 2   global   Surgeries” Performed                Achieved
           3       patient safety   No. of Cases of
                      challenge :                            Zero (0) cases   Monthly   Zero (0) cases
                           “Unintended Retained
                   “Safe Surgery                                      Achieved                       BABY FRIENDLY HOSPITAL
                     Saves Lives”   Foreign Body”
                    To implement the   Incident Rate of MRSA               ≤ 0.4%    Monthly
                        rd
                WHO’s 3   global   Infection                       ≤ 0.4% - Achieved                                                                    HPP
                 patient safety   Incident Rate of ESBL-
           4      challenges :    Klebsiella Pneumonia               ≤ 0.3%    Monthly   ≤ 0.3% - Achieved
                  “Tackling    Infection                                                                                     BULETIN Q 2017
                 Antimicrobial   Incident Rate of ESBL-              ≤ 0.2%    Monthly   ≤ 0.2% - Achieved
                 Resistance”    E.Coli Infection

                   To improve the   Compliance Rate For   Bi-annually  (6   Jan-Jun = 93%
           5   accuracy of Patient   “At least 2 Identifiers   100%  compliance   monthly)   Jul-Dec = 92.1%
                 Identification   Implemented”   rate at each audit
                                                                    *Not achieved

                                                                       -
                 To ensure the   No. of Transfusion   Zero (0) cases  Monthly   2 cases                                          ~Write up by SN Revathi Chandran
                  safety of   Errors (“Actual”)                           Not achieved
           6    Transfusion of   No. of Transfusion         To be determined
                Blood and blood   Errors (“Near Misses”)  later pending   Monthly   31 cases

                  products                national data analysis
                                            and trending

                             No. of Medication   Zero (0) cases   Monthly   46 cases
                              Errors (“Actual”)                     Not achieved

                  To ensure
           7    Medication Safety          To be determined
                             No. of Medication   later pending   Monthly   2 cases
                            Errors (“Near Misses”)  national data analysis
                                            and trending

                            Percentage of Critical
               To improve clinical   Values Notified Within                100%   Monthly   98.24%
               communication by                                     Not achieved
           8    implementing   30 Minutes or less
                 Critical Value   Percentage of Critical                 100%
                 Programme   Values Notified with          Monthly   Not applicable
                              Action Taken

     26                                                                                                                                                            11
   7   8   9   10   11   12   13   14   15   16   17