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Medical Advisory Committee Report
ii. WHO World Alliance on Global Patient Safety Challenges:
1. Clean Care is Safe Care (2005)
Continuous training and monitoring of hand hygiene is part of
the routine activities of the Hospital’s Infection control team
and the compliance is reported during the infection control
meetings.
2. Safe Surgery Saves Lives (2007- 2008)
The compliance to the KPJ “Peri- Operative Check List” is still
being monitored.
3. Tackling Antimicrobial Resistance (2010)
3rd Patient Safety Challenge will concentrate on five key
action areas and of this 2 areas are hospital based i.e:
• Infection control including the promotion of simple and
effective interventions to reduce transmission of resistant
microbes in both hospital and community settings
• Rational drug use and regulation including access, quality,
and misuse of antimicrobial agents
These areas are being addressed by our Prevention and
Control of Infection (PCI) programme, Monitoring and
Surveillance on the Hospital Acquired Infection (HAI) and
development of Antibiotic Guidelines.
Prevention and Control of Infection (PCI)
The manpower for the year 2012 showed 19 Infection Control
Officers / Infection Control Nurse (ICO/ICN) in the Group. All the
accredited and non accredited hospitals comply with the regulatory
requirements of having dedicated ICOs/ ICNs. ICOs/ICNs are being
supported by a total of 260 Link Nurses and personnel to facilitate
and implement the PCI programme in the hospitals.
Monitoring and Surveillance on the Hospital Acquired
Infection (HAI)
Currently there are 6 parameters being monitored. The Surgical
Site Infection (SSI), Ventilator Associated Pneumonia (VAP),
Catheter Related Blood Stream Infection, Catheter Associated
Urinary Tract Infection, MRSA & MRSE. Compliance to the care
bundles pathways is being monitored to reflect the outcome of the
surveillance data.
Antibiotic Guidelines
The antibiogram and antibiotic resistance pattern specific to the
hospitals are being monitored and reported in the Infection Control
and Pharmaceutical and Therapeutic committee. The compiled data
from all the hospitals are discussed in the Group MAC and based
on these data collected antibiotic guidelines will be developed in
the future.
iii.Incident Reporting.
The Group started reporting incidents since 2006 using a
standardized format based on ICPS Classification for Patient
Safety recommended by WHO. The common incidents and
all sentinel events are further analyzed using the Root Cause
Analysis method. These incidents are discussed during the
Clinical Risk Management Committee meeting. The corrective
actions and improvement measures from the Root Cause
Analysis (RCA) findings are disseminated to the hospitals in the
Group as part of Quality Improvement activity .
Monitoring of Medication Error / Adverse Events
Reporting of medication errors including near-miss reporting are
part of the incident reporting program. MAC had emphasized on
the importance of near-miss error reporting and various training
sessions and road shows were conducted this year. This has
increased vigilance amongst the staff and had encouraged both
incident and near miss reporting which is in line with our core
value of ‘Safety’.
There was 0.11% medication related error reported for the year
2012 for 21 hospitals and this denotes a 9.4% reduction from
previous year. It has been emphasized that all incident report
including near-miss must be accompanied with a proper Root
Cause Analysis (RCA) report. The corrective and improvement
measures identified through RCA are shared among other
hospitals as a learning curve to avoid such incidences in future.
Reporting near miss incidents and analyzing it early will ensure
potential errors are cordoned off before it happens.
iv.Research involving Safety and Quality
The KPJ R&D committee is still actively involved in the research
on safety and quality. Several workshops were conducted by
the Chairman on research methodology for the research team
members in 2012.
KPJ Healthcare Berhad had forwarded a research grant to Pusat
Perubatan Universiti Kebangsaan Malaysia (PPUKM) Tissue
Engineering Centre for research on “In vitro Optimal Donor Cell
Density for Maximum Expansion of Keratinocytes Culture for
Formation of Skin Substitute via Tissue Engineering Technique”.
Bed Management System
The KPJ Ipoh’s in-house IT team has developed a system to track
admission of patients till discharge. This Bed Management System
provides information to consultants, admission services, wards,
billing, dietary services and the management team. This system
has been shared with other hospitals in the Group and several of
the hospitals are in the process of installing the system.
Medical Directors’ Meeting
The Medical Directors’ Meeting held twice in 2012, in the month of
January and October, is an avenue for all the Medical Directors of
the hospitals in the KPJ Group to meet and discuss issues raised
by the respective clinicians in the hospitals. It allows the Medical
Directors to share best practices for others to emulate.
Annual Report
2012
KPJ Healthcare Berhad