Page 27 - Buletin Quality 2018

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

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