Page 83 - KPJ_2011

viii. Clinical Indicators
The Group has been collecting, analyzing and
monitoring clinical indicators to improve patient
outcomes. The program started in 2001 with seven
indicators and currently 20 indicators are being
monitored and whereas Patient Safety indicators
that are being monitored include O&G, Diagnostic
Imaging, Radiotherapy and Hospital-wide indicators.
(Table 4)
In 2011, MAC also reviewed the current governing policies
of which currently there are a total of 99 policies complied
into 4 groups i.e. Clinical Governance (CG 001 – 012),
Clinical Services (CS 001 – 050), Hospital Operations (HO
001 – 027) and Pharmacy (PS 001 – 010). To be in line with
KPJ’s objective to be a paper-less organization these policies
have been converted to electronic media called e-Governing
Policy which can be accessed by all Medical Directors &
medical staff and all other KPJ staff in the future.
MAC continues to monitor all other clinical governance
activities for the Group including:
• Mortality reports and Hospital Mortality Review
Committee reports
• Diagnostic groups admitted to the Group
• Antibiogram and Antibiotic Resistance reports, etc.
vi. Monitoring of Medication Error / Adverse Events
As a part of the Incident Reporting program all
medication error and other adverse events are
monitored, root cause analysis (RCA) done and
corrective actions and improvement measures put
into practice routinely.
vii. Safety Research or Studies
Currently the following research safety and quality
studies are being monitored by the KPJ Research &
Development Committee:
KPJ Johor: Epidemiology of Medication Errors
in KPJ Johor Specialist Hospital
KPJ Ipoh: The occurrence of sharp injury
among workers in KPJ Ipoh from
2007 – 2010
KPJ Damansara: 1. Comparison on the effectiveness
of the current teaching module
versus traditional method on
hand hygiene practice among
healthcare providers
2. Effectiveness of Shift Handover
among State Registered Nurses
at KPJ Damansara
KPJ Selangor: Epidemiology of fall and the
effectiveness of the KPJ Fall Risk
Assessment Tool
KPJ Tawakkal: A 12 month study of inpatient’s
complaints at KPJ Tawakkal
ANNUAL REPORT 2011 78