Monitoring Incident Reporting To Improve Quality And Patient Safety : Sharing Malaysia Experience

Abstract

Hospital A monitor 17 types of incidents using incident reporting form. The form will be submitted to the Quality unit and the in charge of that unit will decide whether RCA is necessary or not based on the types of incidents by rating from level 1 (low risk) to level 4 (extreme risk).The RCA committee will investigate the incidence and come out with the conclusion and recommendations for further action by related parties. In order to ensure a good compliance among staff and doctors in this hospital, continuous briefing and teaching were conducted. Data collected will be tabulated on monthly basis and analysis will be done on yearly basis. Comparison of the trending was done between year 2014 and year 2015. For the whole year of 2014, there were 63 cases of clinical incidents reported but reduced to 48 cases in 2015. For non-clinical cases in 2014 there were 9 cases reported which increased to 11 cases in 2015.The most significant reduction of cases was related to OSH related events which reduced from 9 cases in 2014 to 2 cases in 2015. Departure from best clinical practice had recorded 10 cases in 2014 but no case was reported in 2015.Other incidents had not shown a very significant reduction in number of cases from 2014 to 2015.Policy changes were implemented from the following cases:Patient fall which had shown a reduction of cases from 16 in 2014 to 11 cases in 2015; Medication error where changes of policies were done for both pharmacy and nursing services and cases had reduced from 14 cases in 2014 to 12 cases in 2015 and Sentinel event in 2015, where the Management had raised the height of fence at the second floor. There was no change in policies for other types of incidents. Monitoring of incidents had enabled the Management of Hospital A to improve the quality of care and increase