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Annual Report 2013
KPJ HEALTHCARE BERHAD
93
13 Patient Safety Goals (http://patientsafety.moh.gov.my)
1.
To implement clinical governance;
2.
To implement the 1st Global Patient Safety Challenge:
"Clean Care is Safer Care";
3.
To implement the 2nd Global Patient Safety Challenge:
"Safe Surgery Saves Lives";
4.
To implement the 3rd Global Patient Safety Challenge:
"Tackling Antimicrobial Resistance";
5.
To improve the accuracy of patient identi cation;
6.
To ensure the safety of transfusions of blood and blood
products;
7.
To improve medication safety;
8.
To improve clinical communication by implementing critical
value programmes;
9.
To reduce patient falls;
10.
To reduce the incidence of health care associated pressure
ulcers;
11.
To reduce Catheter Related Bloodstream Infection (CRBSI);
12.
To reduce Ventilator Associated Pneumonia (VAP); and
13.
To implement the Patient Safety Incident Reporting and
Learning System.
Prevention and Control of Infection (PCI)
In 2013, there were 19 Infection Control Officers/Infection Control
Nurses (ICOs/ICNs) in the Group. All the accredited and non-
accredited hospitals comply with the regulatory requirements of
having dedicated ICOs/ ICNs. These ICOs/ICNs are supported by a
total of 260 Link Nurses and personnel to facilitate and implement
the PCI programme at the hospitals.
Monitoring and Surveillance on Hospital Acquired Infections
(HAI)
Currently there are six HAI parameters being monitored, namely
Surgical Site Infection (SSI), Ventilator Associated Pneumonia
(VAP), Catheter Related Blood Stream Infection (CRBSI), Catheter
Associated Urinary Tract Infection (CAUTI), MRSA & MRSE
Compliance to the care bundles pathways is being monitored to
re ect the outcome of the surveillance data.
Antibiogram and Antibiotic Usage
Antibiogram, antibiotic resistance patterns and antibiotic usage
of speci c micro-organisms are closely monitored and reported
to the Infection Control and Pharmaceutical and Therapeutic
Committees. Continuous monitoring is being carried out in order
to ensure that the resistance patterns remain below the stipulated
range. The compiled data from all hospitals is discussed among
the Group MAC.
Medical Advisory
Committee Report
ii.
Incident Reporting
The Group began reporting incidents since 2006 using a
standardised format based on the ICPS Classi cation for Patient
Safety recommended by WHO. The common incidents and
all sentinel events are further analysed using the Root Cause
Analysis (RCA) method. These incidents are discussed during
the CRMC meetings. The corrective actions and improvement
measures from the RCA ndings are disseminated to the hospitals
in the Group as part of their quality Improvement activities.
Monitoring of Medication Error / Adverse Events
The CRMC and GroupMAC have placed an emphasis on reporting
medication errors including near-miss incidents. In 2013, several
brainstorm and learning sessions were conducted throughout
the KPJ Group with many new initiatives and innovations
implemented. These measures have increased vigilance amongst
staff and encouraged more effective voluntarily reporting of near-
miss incidents to ensure improvements are continuously made.
In total, there was a 12% decrease in the number of medication
errors in 2013 as compared to the year 2012. There was also a
marked reduction in dispensing/preparation-related errors by as
much as 14% and in administration-related errors by 11% over
2013.
Medical Directors Meeting
The Medical Directors Meeting, held in April 2013, serves as
an avenue for all Medical Directors of the hospitals within 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.