Materia Medica Malaysiana

Patient Safety Council gets into gear

All medical mishaps, large and small, which occur in public hospitals will be documented and dealt with systematically by a Patient Safety Council.

Long in coming but nevertheless welcomed, the council will collect data on medical errors and negligence; investigate the root causes of such cases and recommend strategies for the safety of patients.

Above all, the council, to begin operations soon, will publish regular reports to keep the public informed of such matters — an indication of how critical patient safety has become in the overall agenda of the Health Ministry.

Currently, despite the rise in complaints reported in the New Straits Times on Sept 1, there are no statistics to help the ministry address the problem effectively.

Although an incident-reporting programme exists in public hospitals to help reduce the recurrence of certain kinds of errors or mishaps, the council will likely address larger issues surrounding patient safety and care.

Deputy Director-General of Health Datuk Dr Ismail Merican, who announced this today, said the council will also advise the minister on how to prevent and reduce adverse incidents in public hospitals.

The council will emphasise clinical governance and clinical risk management, he said at a Health Risk Management conference today.

The council, approved by the Cabinet in January 2003, will be chaired by Health Director-General Tan Sri Dr Mohamad Taha Arif. It will comprise senior ministry officials, directors of university hospitals, presidents of professional bodies, the private sector, non-governmental organisations and the president of the Federation of Malaysian Consumers Association.

Thus far, two meetings have been held to finalise the council’s role and mission, terms of reference and strategies.

Six sub-committees will look into data and information, consumer education and empowerment, continuing education, medical safety, transfusion safety, and safe staffing and quality of work life.

Some 30 experts will be involved in the council and its sub-committees with the objective of getting feedback from both public and private hospitals and to ensure that findings are transparent.

"All of us in the health sector are aware that clinical risks and medical errors that infringe on patient safety do occur. The question is how many such incidents have occurred and where, how many get reported, how many are preventable, how many are considered serious, how many have resulted in deaths and what can we do to prevent or minimise such risks," said Dr Ismail.

He stressed that healthcare risk management entailed putting in place policies, processes and procedures for the prevention of risks and the averting of medical errors and facility failures which may otherwise lead to injuries, deaths and financial losses from insurance claims and lawsuits.

The "systems approach" to reduce errors was imperative, he said.

Although there should be acceptance that humans were fallible and errors had to be expected even in the best of organisations, he said mishaps tended to fall in recurrent patterns, regardless of the people involved.

Among the reasons why errors occur in the workplace is time pressure, understaffing, inadequately trained staff, inadequate equipment, fatigue and inexperience.

"The magnitude of an error can vary from a ceiling fan falling off to a generator-set exploding," he said.

But cases may not be reported or documented or may be considered insignificant unless they involve death or severe injury, he added.

He also pointed out that errors in procedures, mistakes in blood transfusion, diagnosis and treatment due to faulty laboratory results, radiological interpretations and mistakes in the administration of medications could lead to undesirable or fatal consequences.

Dr Ismail said that clear strategies to improve patient-doctor communication was essential in the outpatient setting.

The Health Ministry’s incident reporting programme monitors 30 types of incidents in hospitals so that lessons may be learnt to prevent a recurrence of such cases.

These include medical errors, adverse outcomes of procedures, falls in the wards, adverse transfusion reactions, wrong procedures performed, complications in the ICU, injuries to neonates during delivery, and problems faced by patients under anaesthesia.

Dr Ismail said these incidents were monitored every six months nationwide. Incident reporting is also required in the private sector under the Private Healthcare Facilities and Services Act 1998, which is yet to be implemented.