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PatientSAFETYSTRATEGIES111207doc1
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