9. TECHNICAL SPECIFICATION OF MSIA PATIENT SAFETY GOALS

9. TECHNICAL SPECIFICATION OF MALAYSIA PATIENT SAFETY GOALS (2013)SOURCE: Malaysia Patient Safety Goals. Guidelines on Implementation

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9. TECHNICAL SPECIFICATION OF MSIA PATIENT SAFETY GOALS создатель Mind Map: 9. TECHNICAL SPECIFICATION OF MSIA PATIENT SAFETY GOALS

1. 1. TO IMPLEMENT CLINICAL GOVERNANCE

1.1. KPI 1: IMPLEMENTATION OF CLINICAL GOVERNANCE

2. 2. To Implement WHO 1st Global Patient Safety Challenge: " Clean Care is Safer Care"

2.1. KPI 2: HAND HYGEINE COMPLIANCE RATE

2.1.1. TARGET: 75% COMPLIANCE RATE EACH AUDIT

2.1.2. EVERY 3 MONTHS

3. 3. To Implement the WHOs 2nd Global Patient Safety Challenge: " Safe Surgery Saves Lives"

3.1. KPI 3: NO OF "WRONG SURGERIES" PERFORMED

3.1.1. TARGET: 0 CASES

3.2. KPI 4: NO OF CASES " UNINTENDED RETAINED FOREIGN BODY"

3.2.1. TARGET: 0 CASES

3.3. DATA COLLECTION MONTHLY

4. 4. To Implement WHOs 3rd Global Patient Safety Challenges- " Taking Antimicrobial Resistance"

4.1. Page 1

4.2. Page 2

4.3. KPI 5: INCIDENCE RATE OF MRSA INFECTION

4.3.1. TARGET: < THAN 0.4 %

4.4. KPI 6: INCIDENCE RATE OF ESBL KLEBSIELLA PNEUMONIA INFECTION

4.4.1. TARGET: < THAN 0.3 %

4.5. KPI 7: INCIDENCE RATE OF ESBL- E.COLI INFECTION

4.5.1. TARGET: < THAN 0.2%

4.6. DATA COLLECTION MONTHLY

5. 5. To Improve Accuracy of Patient Identification

5.1. KPI 8: COMPLIANCE RATE FOR "AT LEAST 2 IDENTIFIERS IMPLEMENTED"

5.1.1. TARGET: 100% COMPLIANCE RATE EACH AUDIT

5.2. DATA COLLECTION 6 MONTHLY

6. 6. To Ensure Safety Transfusion of Blood & Blood Products

6.1. KPI 9: NUMBER OF TRANSFUSION ERRORS ("ACTUAL")

6.1.1. TARGET: 0 CASES

6.2. KPI 10: NUMBER OF TRANSFUSION ERRORS ("NEAR MISSES")

6.2.1. TARGET: TO DETERMINED LATER PENDING NATIONAL DATA ANALYSIS & TRENDING

6.3. DATA COLLECTION MONTHLY

7. 7. To Ensure Medication Safety

7.1. KPI 11: NUMBER OF MEDICATION ERRORS ("ACTUAL")

7.1.1. TARGET: 0 CASES

7.2. KPI 12: NUMBER OF MEDICATION ERRORS ("NEAR MISSES")

7.2.1. TARGET: TO DETERMINED LATER PENDING NATIONAL DATA ANALYSIS & TRENDING

7.3. DATA COLLECTION MONTHLY

8. 8. To Improve Clinical Communication by Implementing Critical Value Programme

8.1. Page 1

8.2. Page 2

8.3. KPI 13: PERCENTAGE OF CRITICAL VALUES NOTIFIED WITHIN 30 MINS OR LESS

8.3.1. TARGET: 100%

8.4. DATA COLLECTION MONTHLY

9. 9. To Reduce Patient Fall

9.1. KPI 14: PERCENTAGE REDUCTION IN NO OF FALLS (ADULTS)

9.1.1. TARGET: 10% REDUCTION OR MORE

9.2. KPI 15: PERCENTAGE REDUCTION IN NO OF FALLS (PEDIATRICS)

9.2.1. TARGET: 10% REDUCTION OR MORE

9.3. DATA COLLECTION MONTHLY

10. 10. To Reduce Incidence of Healthcare Associated Pressure Ulcers

10.1. KPI 16: INCIDENCE RATE OF PRESSURE ULCERS

10.1.1. TARGET: < THAN 3%

10.2. DATA COLLECTION 3 MONTHLY

11. 11. To Reduce Catheter- Related Blood Stream Infection in ICU

11.1. KPI 17: RATE OF CRBSI (NUMBER OF CRBSI PER 1000 CATHETER-DAYS)

11.1.1. TARGET: < THAN 5 PER 1000 CATHETER-DAYS

11.2. DATA COLLECTION MONTHLY

12. 12. To Reduce Ventilator Associated Penumonia in ICU

12.1. KPI 18: RATE OF VAP (NO OF VAP PER 1000 VENTILATOR DAYS

12.1.1. TARGET: < THAN 10 PER 1000 VENTILATOR DAYS

12.2. DATA COLLECTION MONTHLY

13. 13. To Implement an Incident Reporting & Learning System

13.1. KPI 19: IMPLEMENTATION OF FACILITY WIDE INCIDENT REPORTING SYSTEM OR OTHER METHODS TO INVESTIGATE INCIDENT

13.1.1. TARGET- SYSTEM IMPLEMENTED

13.1.2. DATA COLLEECTION YEARLY

14. SUMMARY PERMORMANCE INDICATOR MATRIX

15. Source: Malaysia Patient Safety Goals. Guidelines in Implementation & Surveillance by MOH Malaysia & Patient Safety Council Malaysia ( 2013)