Sunday February 24, 2013
Mechanisms in place to ensure patient safety
1. System-wide mechanisms have been established to ensure that patients are safe, including:
> National Incident Reporting and Learning system (for government hospitals and clinics and dental facilities)
> Hospital and Health Clinic Accreditation to identify conditions of unsafe practice and supporting healthcare organisations that promote safe care. By complying with the standards, the potential for adverse events occurring within healthcare and service organisations can be greatly reduced.
> Clinical Audit, which include Peri-Operative Mortality Review (POMR), is a surgical mortality audit. An independent peer review committee evaluates the quality of care against agreed professional standards.
> Independent inquiries to investigate and assess issues related to complaints and serious incidents.
> Regular training for staff to ensure continued competency.
> Development of clinical practice guidelines, manuals, standard operating procedures etc by the Health Technology Assessment unit of the ministry.
> Ventilator-Associated pneumonia care bundle introduced in January 2007 in intensive care units to prevent ventilator-associated pneumonia (a major cause of death in ICU patients who were being ventilated).
Laws and action that can be taken
At private healthcare facilities
There are two manuals developed by the Private Medical Practice Control Section (CKAPS) of the ministry's medical practice division to ensure safety of patients. The manuals are Incident Reporting, and Assessable Death.
The first is to ensure that a private healthcare facility or service (PHFS) reports to the Health director-general (or any person authorised by the D-G) any unforeseeable or unanticipated incident that occurs within the PHFS.
The second requirement is for “assessable death” reporting. The person in charge of a PHFS shall ensure that every medical or dental practitioner who administers an anaesthetic or medical or surgical procedure or uses any medical technology on any patient, whereby an assessable death occurs within the PHFS, shall notify to the D-G particulars of the incident as required by law. An investigation is carried out to identify and implement preventative and remedial actions.
In public healthcare facilities
> The D-G circular mandates the implementation of an Incident Reporting and Learning System with 29 mandatory “incidents” chosen for reporting and prevention. They are capable of providing information that gives meaningful insight into the nature of the underlying system defects that caused the incident.
> Rather than assure a minimum standard of care, learning systems are designed to foster continuous improvements in care delivery by identifying themes, reducing variation, facilitating the sharing of best practices, and stimulating system-wide improvements.
> Following analysis of underlying causes through mini root cause analysis (RCA) of full RCA, recommendations or action plans are made for system re-design to improve performance and reduce errors and injuries rather than being targeted at individual performance. It is based on the concept that individual error results from system defects, and will recur with another person at another time if defects are not remedied.
> The recommended action plan includes person responsible, actions needed to develop and implement the plan, the required timeline for implementation and methods to assess the effectiveness of the actions. If the resolution of the problem requires organisation-wide changes, there is a process of referring it to the appropriate forum.
> There are also systems to ensure that recommended actions are communicated to the staff/ employees. Improvement strategies aimed at reducing risk to future patients are implemented and monitored by the organisation. Where appropriate, local staff learn lessons and change practice in order to improve safety and quality of care for patients.
> Source: Health Ministry medical care quality section (medical development division)/ Patient Safety Council of Malaysia.