PatientSAFETYSTRATEGIES111207doc1.docx

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ENHANCINGSAFETYANDQUALITYINMALAYSIANHOSPITALS–THEWAYAHEAD

1.Introduction

IntheUnitedStates,areportbytheInstituteofMedicineentitled“ToErrisHuman”inNovember1999succeededincapturingtheattentionoftheAmericanpopulationandmadetheissueofpatientsafetyanationalpriority.SimilarlyinAustralia,theQualityInAustralianHealthCareStudyin1995alsogalvanisednationalactiontoenhancepatientsafetywhileintheUnitedKingdom,theBristolInquiryhelpedfocusprofessionalandpublicattentiononpatientsafetyinamannerunprecedentedbothforitsdepthandfortheextentofprofessionalinvolvement.Today,reducingmedicalerrorsandimprovingpatientsafetyhavebecomecriticalissuesinthehealthcareindustryandthismovementiscurrentlybeingledbytheWorldAllianceforPatientSafety,whichwasestablishedin2004bytheWorldHealthOrganisationandtowhichMalaysiahadpledgeditsfullsupportinMay2006.

2.ThePatientSafetyCouncilofMalaysia（PSCoM）

TheMinistryofHealthMalaysiahasunderlineditscommitmenttopatientsafetywiththeformationofthePatientSafetyCouncilofMalaysia,formalisedbytheMalaysianCabinetfollowingtherecommendationsoftheHonourableMinisterofHealthon29thJanuary2003.ThisCouncilischairedbytheDirector-GeneralofHealthMalaysiaandiscomprisedofhealth-relatednon-governmentalorganizations（NGO）suchasMalaysianMedicalAssociation（MMA）andAssociationofPrivateHospitalsMalaysia（APHM）,consumerrepresentatives,representativesofUniversityhospitalsandthevariousDivisionsintheMinistryofHealthaswellasprominentmembersoftheMalaysiansocietywhohavegreatinterestinthehealthcaresystem.

ThefollowingarethePatientSafetyCouncilMembers:

1.Director-GeneralofHealthMalaysia–Chairman

2.DeputyD-G（Medical）

3.DeputyD-G（PublicHealth）

4.DeputyD-G（ResearchandTechnicalSupport）

5.PresidentoftheMalaysianMedicalAssociation（MMA）

6.PresidentoftheMalaysianSocietyforQualityinHealth（MSQH）

7.PresidentoftheAssociationofPrivateHospitalsMalaysia（APHM）

8.DirectorofKualaLumpurHospital

9.DirectorofUniversityMalayaMedicalCentre（UMMC）

10.DirectorofHospitalUniversitiKebangsaanMalaysia（UKM）,Cheras

11.DirectorofHospitalUniversitiSainsMalaysiaUSM,KubangKerian

12.DirectorofPharmaceuticalServicesDivision,MOH

13.DirectorofOralHealthDivision,MOH

14.DirectoroftheInstituteforHealthManagement（IHM）

15.Director,MedicalDevelopmentDivision,MOH

16.Director,MedicalPracticeDivision,MOH

17.SecretaryoftheMalaysianMedicalCouncil（MMC）

18.DirectorofNursingDivision,MOH

19.Deputy-Director（QualityinMedicalCareSection,MedicalDevelopmentDivision）–Secretariat

ThePatientSafetyCouncilofMalaysiaisabodysetuptoadvisetheHonourableMinisterofHealthonthesituationofpreventableadverseeventsaswellastherelevantstrategiesandactionstobetakeninordertopreventorminimisethesepreventableadverseeventsinhealthcare.ItaimstopromotesystemicimprovementsinthesafetyandqualityofhealthcareinMalaysiasoastoensurethattheMalaysianpublichasaccesstogoodclinicalgovernanceandtransparencyaswellasaccountabilityintheprovisionofqualityhealthcaretoourpopulation.

ToassistthePatientSafetyCouncilinitsmission,4TechnicalAdvisoryCommittees（TAC）havebeenformedviz:

MedicalCareSafetyTAC

Chairperson:

TanSriDato’Dr.AbuBakarSuleiman,

President,InternationalMedicalUniversity

ContinuingProfessionalDevelopment（CPD）&ConsumerEducationTAC

Chairperson:

Prof.MadyaDr.AbdulRashidb.AbdulRahman,

VicePresident,ResearchandInternational,

CyberjayaUniversityCollegeofMedicalSciences,Cyberjaya

MedicationSafetyTAC

Chairperson:

EncikJohnC.PChang,

President,MalaysianPharmaceuticalAssociation

TransfusionSafetyTAC

Chairperson:

Dato’Dr.YasminAyub,Director,NationalBloodCentre,KL

2.1MissionofthePatientSafetyCouncilofMalaysia（PSCoM）

ThemissionofthePatientSafetyCouncilofMalaysia（PSCoM）istodevelopasaferMalaysianhealthcaresystem.ThePSCoMwillleadnationaleffortstoimprovethesafetyofhealthcaretopatientsbypromotingsystemicimprovementswithaparticularfocusonRiskManagementinordertominimisethelikelihoodofmedicalerrorsandtheadverseeffectsthatresultfromthem.Theaimistodevelopbettersystemsofcareandmeasurableimprovementsinpatientsafety.

2.2TermsofReferenceofthePatientSafetyCouncilofMalaysia

I.AdvisetheHonourableHealthMinisteronnationalstrategiesandpriorityareasforpatientsafetyandqualityimprovementinhealthcare

II.Identifyareasofconcernregardingpatientsafetyandtomonitortheperformance/outcomeintheseareas.ReportstobetabledattheCouncil’smeetings

III.Discussissuesonpatientsafetyandtodevelopmeanstoovercometheproblems

IV.Planapreventionstrategyforpatientsafetyby:

•empoweringconsumerstoparticipateinpromotingpatientsafety

•implementingevidence-basedpractices

•developinganationalframeworkforadverseeventmonitoring,managementandprevention

V.PrepareAnnualreportsonPatientSafetyperformance

VI.Establishanelectronicdatabaseonpatientsafetyandmedicalerrors

2.3PhilosophyRegardingMedicalErrorsAndPreventableAdverseEvents

ThePatientSafetyCouncilofMalaysiaiscommittedtoimprovingpatientsafetyinMalaysiaandrecognisesthat:

∙healthcarewillalwayscarryadegreeofriskforthebenefitsthatarehopedtobeattained

∙someadverseeventswilloccurevenwhenwehavethebestpeopleinthebestfacilitiesprovidingthiscare

∙asignificantnumberofadverseeventscanbepreventedormanagedbetterwhentheydooccur

∙oureffortstoimprovethesafetyofpatientcaremustrecognizethattherearenosimplefixesforcomplexadaptivesystemssuchasthehealthcaresystem

ItisthebeliefofthePatientSafetyCouncilthatthe“systemsapproach”isthebestwaytomanagetheproblemofmedicalerrorsandpreventableadverseevents.Thiswillrequireafundamentalchangeinmindsettoachieveajustcultureratherthanthepresent“blamingculture”.Whenincidentsoccur,theemphasisshouldnotbeonblamingand“scape-goating”buttofindoutwhyoursystemdefencesfailed.

Inthisnew“justculture”,individualsmustbeencouragedtoseek,identifyandreporterrorsaswellassystemfailuresinorderfororganisationallearningtooccur.Thereisthusagreatneedtoestablishtheunderlyingcause（s）ofseriousincidentsthroughrootcauseanalysis,wherethecausesofadversepatientincidentsmustbeproperlyunderstood,lessonslearnedandsuitableimprovementsmadetosecureareductionintheriskofharmtofuturepatients.

TheCouncilalsobelievesthatitisnotsufficienttolearnandimproveonlyfromthingsthatgowrong.Engaginginproactiveclinicalriskmanagementactivity,inadditiontothereactiveprocessofincidentmanagement,willenabletheidentificationofmanythingsthatcouldgowrongaspartofasystematicapproachtoriskassessment.Errorreductionmustbemadeanexplicitorganisationalgoal.

2.4ApproachtoMedicalErrorsandPreventableAdverseEventsAdopted

bythePSCoM:

ThePatientSafetyCouncilwilladoptthe“Systemsapproach”tomanagingmedical

errorsandPreventableadverseevents.Thisapproachhasbeendemonstratedby

stronginternationalevidencetobetherightapproachtothemanagementof

preventableadverseevents.

Systemsneedtobedesignedto:

（a）helppreventerrors

（b）makeerrorsdetectableorvisiblesothattheycanbeintercepted

（c）mitigatetheadverseeffectsofERRORSwhentheyarenotdetectedorintercepted

Latentconditionsmustbeidentifiedandremediedbeforeanadverseeventoccurs

andthisconstitutesPro-activeRiskManagement.

3.StrategiesToAddressTheProblemOfPreventableAdverseEventsInMalaysia

Becausetherehavebeen,todate,nomajornationalepidemiologicalstudiesonthemagnitudeofthisprobleminMalaysia,thePatientSafetyCouncilwill“adoptandadapt”thelessonslearntaswellasstrategiesrecommendedbythevariousstudiesontheepidemiologyofmedicalerrorandpreventableadverseeventsconductedintheUSA,theUnitedKingdomandAustralia,whileawaitingtheresultsofspeciallycommissionedpatientsafetystudiesunderthe9thMalaysianPlan.

ToassistthePatientSafetyCouncilinthedevelopmentofstrategiestoadvancepatientsafetyinMalaysia,aninternationalconsultantonPatientSafety,Dr.MareeBellamyfromNSW,AustraliawascommissionedbytheWHOfromApril2005toJuly2005.From2006to2007,anotherinternationalconsultantonpatientsafetyfromtheNationalHealthServiceintheUnitedKingdom,Mr.StuartEmslieassistedtheMOHdevelopstandardsforClinicalRiskManagementaswellasrefinethepatientsafetystrategiesforMalaysia.Afteralengthyconsultationprocess,togetherwiththeeffortsofthemembersoftheMedicalCareSafetyTechnicalAdvisoryCommitteeofthePatientSafetyCouncil,thefollowingstrategieswereproposedforapprovalandadoption:

3.1OfficiallyAdopttheClinicalGovernanceModelastheOrganisationalFrameworkforPatientSafety

MechanismstoensurethattheCEO/HospitalDirectorisaccountableforclinicalandorganisationalperformance,andforthedeliveryofapatient-centred,safe,high-qualityandefficienthealthserviceshouldbedeveloped.InClinicalGovernance,theroleofhealthcareleadersistodevelopandnurtureacultureofopenness,questioningandlearningratherthanablamingcultureand