PATIENT SAFETY PATIENT SAFETY ISSUES

associated Pneumonia (VAP) dan SSI
associated Pneumonia (VAP) dan SSI
for Ventilator-
for Ventilator-
51 51















SSI (21.9% & 21.6%)
SSI (21.9% & 21.6%)
Prevalence Survey
Prevalence Survey
Pneumonia (24.5% & 26.6%)
Pneumonia (24.5% & 26.6%)







”Targeted surveillance”
”Targeted surveillance”
















: in 2004 : in 2004 Concentrating on ICUs in 14 State Concentrating on ICUs in 14 State hospitals hospitals

52 52
Norms for Infection Control Nurse
Norms for Infection Control Nurse










every ward to train a 'link
every ward to train a 'link









( 1 : 250 occcupied beds)
( 1 : 250 occcupied beds)












in MOH hospitals
in MOH hospitals




Determining:
Determining:










nurse' nurse'










- - - -


„ „

53 53
Malaysian Infection Control Society
Malaysian Infection Control Society

courses courses ”Hand ”Hand “Standard “Standard


Training & Continuing Education:
Training & Continuing Education:

course conducted by
course conducted by
Pinang Pinang



Development of “Post-Basic”
Development of “Post-Basic”











dan dan 1,500 persons trained in all States 1,500 persons trained in all States & Pulau & Pulau
in Infection Control
in Infection Control
duration duration Awareness Programme & Awareness Programme &















“APSIC” “APSIC” 2 weeks 2 weeks Hygiene” Hygiene” Precautions” Precautions” except Perak except Perak


















- - - -

54 54
MORTALITY REVIEW










PERI-OPERATIVE

In order to improve the quality of patient care
In order to improve the quality of patient care
Mortality Review:
55 55
Mortality Review:








remediable factors leading to mortality
remediable factors leading to mortality

Patients who had undergone surgery
Patients who had undergone surgery
within the length of hospital stay of
within the length of hospital stay of
A national level study to identify:
A national level study to identify:



















Perioperative
Perioperative

56 56




Definition of perioperative
Definition of perioperative
A death occurring within the
A death occurring within the
of a length of hospital stay of a length of hospital stay surgical or gynaecological surgical or gynaecological procedure done under general or procedure done under general or regional anaesthesia regional anaesthesia
















mortality:
mortality:

Surgical Doctor Surgical Head Review Case 57 57















POMR REPORTING SYSTEM






Document & inform doctor
Death Occurs in Wards









Ward Sister- biodata POMR Coordinator (Hospital Matron) POMR Secretariat For Assessment by POMR Committee Prepares Reports/Case summaries & Recommendations

























Anaesthetic Doctor Head of Anaesthesia review Case

58 58

















& 3rd POMR Reports 2 nd Inadequate pre-operative preparation, Inadequate pre-operative preparation, assessment and lack of consultation identified assessment and lack of consultation identified as major contributing factors as major contributing factors
POMR Findings
POMR Findings
Executive Summary

33% of these deaths were in patients
33% of these deaths were in patients
59 59


IV &V IV &V 43% of patients had associated 43% of patients had associated






85% of deaths occurred during
85% of deaths occurred during







POMR Deaths
POMR Deaths




















































„ „ emergency procedures emergency procedures „ „ > 60 years old > 60 years old 62% of patients were ASA - „ „ 62% of patients were ASA - „ „ medical illness medical illness

Reorganising the Operating Theatre services to
Reorganising the Operating Theatre services to



60 60

RECOMMENDATIONS OF THE POMR
RECOMMENDATIONS OF THE POMR
















give priority to Emergency cases
give priority to Emergency cases


COMMITTEE
COMMITTEE































ill patients Developing protocols and guidelines to manage Developing protocols and guidelines to manage ill patients Ensuring appropriate pre-operative consultation Ensuring appropriate pre-operative consultation and optimisation of patients. and optimisation of patients. -adequate assessment and preparation of -adequate assessment and preparation of patients for surgery. patients for surgery. Ensuring



















„ „ „ „ „ „ „ „

skills in carrying out operations
skills in carrying out operations



61 61
Ensuring the adequate matching of surgical
Ensuring the adequate matching of surgical
RECOMMENDATIONS OF THE POMR
RECOMMENDATIONS OF THE POMR


to manage the growing
to manage the growing
















COMMITTEE
COMMITTEE






















and anaesthetic
and anaesthetic







specialists Increasing the number of anaesthetic Increasing the number of anaesthetic in the hospitals in the hospitals specialists Properly-equipped and staffed trauma centres Properly-equipped and staffed trauma centres and burns units and burns units number of major trauma and burns cases. number of major trauma and burns cases.


















„ „ „ „ „ „

Increasing the number of Intensive Care
Increasing the number of Intensive Care

RECOMMENDATIONS OF THE POMR COMMITTEE
RECOMMENDATIONS OF THE POMR COMMITTEE
62 62






and creating step-down
and creating step-down
















































Unit beds Unit beds facilities such as High Dependency facilities such as High Dependency Wards (HDW) Wards (HDW) Ensuring the effective and appropriate Ensuring the effective and appropriate utilisation of these beds utilisation of these beds





















„ „ „ „

RECOMMENDATIONS OF THE POMR COMMITTEE
RECOMMENDATIONS OF THE POMR COMMITTEE
63 63 at the hospitals at the hospitals
Forming retrieval teams to transfer ill
Forming retrieval teams to transfer ill
undertaken if adequate critical care
undertaken if adequate critical care
from smaller
from smaller

should only be
should only be





































































„ Complex surgery „ Complex surgery facilities are available facilities are available „ „ and unstable patients and unstable patients centres to higher levels of care centres to higher levels of care Conducting regular Morbidity and „ Conducting regular Morbidity and „ Mortality meetings Mortality meetings

64 64















Products of POMR
Products of POMR










OT OT for emergency for emergency
POMR Assessors Manual
POMR Assessors Manual
documentation system
documentation system
POMR Report-biennial
POMR Report-biennial
COTDS-computerised
COTDS-computerised
20 th 20 th Guidelines for emergency cases Guidelines for emergency cases TAC –technical advisory committee TAC –technical advisory committee ICU/HDU beds, burns unit in major ICU/HDU beds, burns unit in major






POMR Bulletin-
POMR Bulletin-






hospitals hospitals Opening of two OTs Opening of two OTs












• • cases cases



„ „ „ „ „ „ „ „ „ „ „ „ „ „

65 65
Surgical, Anaesthetic and Trauma Services,
2. Improvement in OT, ICU and HDU services.
planning for the 8th and 9th Malaysia Plan.
facility development and Human Resource
4. Computerised OT Documentation System.
3. Improvement in Training and Supervision.
1. Developments of policies and guidelines.
5. Provide inputs for future development of






























ACHIEVEMENTS :

66 66
Mortality Review
Mortality Review

“major “major






















(POMR) (POMR) Actions taken as a result of reports) Actions taken as a result of reports) POLICY : Pediatric POLICY : Pediatric can only be performed by can only be performed by 2. Special ambulance system to 2. Special ambulance system to transport neonatal patients transport neonatal patients












Perioperative
Perioperative











surgery” surgery” Paediatric Surgeons Paediatric Surgeons













1. 1.

67 67
Policies and recommendations
Policies and recommendations

in each Paediatric ICU Established in each Paediatric ICU Established State or Regionally State or Regionally Public patients needing care not Public patients needing care not available in Government hospitals available in Government hospitals can have the care outsourced from can have the care outsourced from private hospitals (out-sourcing of a private hospitals (out-sourcing of a service) when referred by a service) whe

68 68

National Audit on Adult Intensive
National Audit on Adult Intensive







(NAICU) (NAICU)








Care Units
Care Units

and hence improve the quality of
provision of ICU services in Malaysia
provision of ICU services in Malaysia
and hence improve the quality of
identify remediable factors in the
69 69






National Adult ICU Audit
National Adult ICU Audit










































Objectives:
Objectives:














To To identify remediable factors in the ICU services ICU services

70 70




all State hospitals (>4 ICU beds)
all State hospitals (>4 ICU beds)
“SYNAPSE SOFTWARE”
“SYNAPSE SOFTWARE”
National Adult ICU Audit
National Adult ICU Audit



















14 Hospitals involved:
14 Hospitals involved:





















format – data collection using a standard data collection using a standard format – of ICU data Analisis of ICU data Analisis



















- -

71 71




























Findings

72 72

Average Average No. Bed No. Bed 9.5 9.5 3.3 3.3 10.8 10.8 5.8 5.8 6.1 6.1









ICU beds by sector (as on August 2003)
ICU beds by sector (as on August 2003)

No. ICU No. ICU Beds (%) Beds (%) 142 (27.9) 142 (27.9) 80 (15.7) 80 (15.7) 54 (10.6) 54 (10.6) 233 (45.8) 233 (45.8) 509 (100) 509 (100)













No. ICU No. ICU 15 15 24 24 5 5 40 40 84 84 monitoring plus mechanical ventilation Government ICU beds = 276 (54.2%) ICU beds = 1.1% of total hospital beds






















MOH state hospitals MOH state hospitals MOH district hospitals MOH district hospitals University / Military hospitals University / Military hospitals Private hospitals Private hospitals Total Total Definition of ICU bed = hemodynamic

Total referrals 8615 4911 (57%) denied admission 73 73





















N
Referrals for ICU admission
M

L

K
Not Admitted
J

I

H

G

Admitted
F
E


D

C

B

A


1600 1400 1200 1000 800 600 400 200 0

74 74



























Findings Findings Severe shortage of ICU beds Severe shortage of ICU beds Performance of ICU comparable with Performance of ICU comparable with High percentage of admissions from High percentage of admissions from operative-emergency patients operative-emergency patients Disproportionately high mortality in Disproportionately high mortality in operative elective patients operative elective patients















































„ „ „ „ overseas centres overseas centres „ „ „ „

75 75
In-depth audit of outcome for major
In-depth audit of outcome for major












Recommendations
Recommendations


























































„ „ elective surgeries elective surgeries Urgent need to increase intensive „ Urgent need to increase intensive „ care facilities care facilities

REPORTING



INCIDENT






























‹

occurrences which could have (“near-miss”)
occurrences which could have (“near-miss”)
to the to the Root Cause Analysis / Problem analysis conducted at Root Cause Analysis / Problem analysis conducted at







a system of reporting any unintended
a system of reporting any unintended




or caused harm (“adverse events”)
or caused harm (“adverse events”)


INCIDENT REPORTING
INCIDENT REPORTING






































patient patient monitored nationally 31 “incidents” monitored nationally 31 “incidents” local level local level

78 78




INCIDENTS MONITORED FOR ALL
INCIDENTS MONITORED FOR ALL


















LOCATIONS LOCATIONS : : 2. Adverse Drug Reaction 2. Adverse Drug Reaction 3. Adverse Transfusion Reaction 3. Adverse Transfusion Reaction 5. Adverse Outcome of Procedure 5. Adverse Outcome of Procedure related Incidents related Incidents 8. Patient Falls in Ward 8. Patient Falls in Ward 10. Needle Stick Injury 10. Needle Stick Injury 11. Complaints by Patients and / or Relatives 11. C



















































„ 1. Medication Error „ 1. Medication Error „ „ „ „ 4. Transfusion Error „ „ 4. Transfusion Error „ „ 6. AOR Discharges „ „ 6. AOR Discharges 7. Equipment- „ 7. Equipment- „ „ „ 9. Staff falls in Ward „ „ 9. Staff falls in Ward „ „ „ „

79 79
OPERATING THEATRE INCIDENTS
OPERATING THEATRE INCIDENTS









































































„ 1. Cardiac / respiratory Arrest 1. Cardiac / respiratory Arrest „ 2. Wrong Procedure Performed „ 2. Wrong Procedure Performed „ 3. Prolonged Stay in Recovery Room for „ 3. Prolonged Stay in Recovery Room for „ more than 2 hours more than 2 hours 4. Operative Consent Error „ „ 4. Operative Consent Error 5. Incorrect Instrument or Swab Count „ „ 5. Incorrect Instrument or Swab Count 6. Elective Surgery Cancelled in OT

Death of Fetus Weighing > 800grams or >
Death of Fetus Weighing > 800grams or >
80 80
Readmission to ICU within 24 hours of
Readmission to ICU within 24 hours of









Complications during Stay in ICU
Complications during Stay in ICU










LABOUR ROOM INCIDENTS
LABOUR ROOM INCIDENTS




Accidental Extubation
28 weeks of gestation
Accidental Extubation
28 weeks of gestation
Discharge to Ward
Discharge to Ward
Unexpected Death
Unexpected Death
Score Score Injury to Neonate during Delivery Injury to Neonate during Delivery




ICU INCIDENTS
ICU INCIDENTS


Poor Apgar Poor Apgar





















„ „ „ „ „ „ „ „ „ „ „ „ „ „

PRIVATE HEALTHCARE FACILITIES & SERVICES ACT
PRIVATE HEALTHCARE FACILITIES & SERVICES ACT
81 81































of patients of patients to patients involving: to patients involving: injuries injuries falls resulting in fractures, dislocations, concussions or falls resulting in fractures, dislocations, concussions or life-threatening (or potentially fatal) complications of life-threatening (or potentially fatal) complications of life-threatening (or potentially fatal) transfusion errors or life-threatening (or potentially fatal) transfusion errors
1998 1998 Section 37 REPORTABLE INCIDENTS Section 37 REPORTABLE INCIDENTS : : lacerations extending beyond the epidermis into deep tissue or lacerations extending beyond the epidermis into deep tissue or involving > 20 % surface area (adult) involving > 20 % surface area (adult)































- - Unexplained Deaths Unexplained Deaths brain or spinal cord brain or spinal cord which threaten vital structures which threaten vital structures anesthesia anesthesia reactions reactions 2nd or 3rd degree burns 2nd or 3rd degree burns or 15 % (child) or 15 % (child)
Injuries Injuries • • • • • • • • • •











„ „ „ „

that that 82 82


PRIVATE HEALTHCARE FACILITIES & SERVICES ACT 1998
PRIVATE HEALTHCARE FACILITIES & SERVICES ACT 1998
















REPORTABLE INCIDENTS
REPORTABLE INCIDENTS













: : resulting in death or personal resulting in death or personal of patients by of patients by Malfunction or intentional or accidental Malfunction or intentional or accidental misuse of patient care equipment misuse of patient care equipment would have significantly adversely would have significantly adversely affected a patient or employees of the affected a patient or employees of the














- - Assault or battery Assault or battery employees or other persons employees or other persons healthcare premises healthcare premises












Fires Fires injury injury












„ „ „ „ „ „

or discharge to the wrong
or discharge to the wrong
83 83
PRIVATE HEALTHCARE FACILITIES & SERVICES ACT 1998
PRIVATE HEALTHCARE FACILITIES & SERVICES ACT 1998

that resulted in or
that resulted in or
or wrong or wrong resulting in harm to the resulting in harm to the











REPORTABLE INCIDENTS
REPORTABLE INCIDENTS













: : contributed significantly to an “incident” contributed significantly to an “incident”



of a patient of a patient Surgery on the wrong patient Surgery on the wrong patient









- - Utility system failure Utility system failure Infant abduction Infant abduction Medication error









Suicide Suicide family family Rape Rape body part body part Medication error patient patient















„ „ „ „ „ „ „ „ „ „ „ „

84 84




ACCREDITATION
ACCREDITATION





PROGRAMME
PROGRAMME

HOSPITAL
HOSPITAL

DEFINITION OF ACCREDITATION
DEFINITION OF ACCREDITATION
85 85
to accurately assess level of performance in relation to
to accurately assess level of performance in relation to
“a self-assessment and external peer review process
“a self-assessment and external peer review process






to implement ways to continuously improve the
to implement ways to continuously improve the




















ISQua definition : Federation definition : Federation ISQua Operating Rules 1998 Operating Rules 1998

established standards and
established standards and







healthcare system”
healthcare system”

MALAYSIAN HOSPITAL ACCREDITATION
86 86







Housekeeping Housekeeping Pathology Pathology Linen Linen Radiology Radiology Medical Records Medical Records Medical-Surgical Medical-Surgical Nursing Nursing Operating Suite Operating Suite Pharmacy Pharmacy General General Organization and Management. Human Resource Development and Quality Improvement Activities
















STANDARDS
Management. SAFETY

„ „ „ „ „ „ „ „ „ „ „ „ „ „ „ „ „ „ „ „ Policies and Procedures Facilities and Equipment.
























Emergency Emergency Allied Health Pro. Allied Health Pro. Anaesthetic Anaesthetic Critical Care Services Critical Care Services CSSU CSSU Day Only Surgery Day Only Surgery Engineering & Building Engineering & Building Environmental Environmental Food Food Governing Body/Mgmt. Governing Body/Mgmt. AREAS PRIORITY



















„ „ „ „ „ „ „ „ „ „ „ „ „ „ „ „ „ „ „ „ OF

87 87


SURVEYORS’IDENTIFICATION/APPOINTMENT/CONCENSUS



PREPARATION & STANDARDS INTERPRETATION








SELF-EVALUATION BY HOSPITALS
VOLUNTARY REQUEST
AGREEMENT ON SURVEY DATES

PRE-SURVEY ASSESSMENT
SURVEY COORDINATION




SURVEY SURVEY

3 YEARS FULL ACCREDITATION Ð 1 YEAR ACCREDITATION + 2 YEARS AWARD FOCUS SURVEY NON-ACCREDITATION 88 88

QUALITY IMPROVEMENT IS A
QUALITY IMPROVEMENT IS A




NEVER-ENDING JOURNEY,
NEVER-ENDING JOURNEY,
AND NOT A DESTINATION
AND NOT A DESTINATION

90 90


















THANK YOU,
THANK YOU,
THANK YOU,
ATTENTION
ATTENTION
ATTENTION
FOR YOUR
FOR YOUR
FOR YOUR