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
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