Page 20 - MALAYSIAN PATIENT SAFETY GOALS

PATIENT SAFETY GOAL NO.2

TO IMPLEMENT THE WHO’S 1st GLOBAL PATIENT SAFETY

CHALLENGE : ”CLEAN CARE IS SAFER CARE”

KPI NO.2 HAND HYGIENE COMPLIANCE RATE

INTRODUCTION
Infection control plays an important role in reducing Hospital Aquired

Infection (HAI), as it is one of the main cause of morbidity and mortality in
healthcare facilities.

In order to reduce healthcare associated infection (HAI) Ministry of Health
Malaysia has implemented hand hygiene programe.

The principles of 5 moments hand hygiene is strictly adhered in healthcare

facilities where the nurses and doctors remind each other.

OBJECTIVE

To achieve ≥ 75% compliance on hand hygiene practices.

ROLES AND RESPONSIBILITIES OF NURSES

1.Education and Training
1.1 Orientation
- Hospital level - by Infection Control Nurses
i. All new staff

ii. All trained nurses in Hospital
- Department and ward level - by Ward Link Nurse

i. All new staffs in the ward
ii. Student nurse who practice in the ward
iii. All in patient during admission or transfer in

1.2 CME / CNE
- Tentative with the schedule set by Nursing unit

- Tentative with the schedule set by Department

1.3 Demonstration - by Infection Control Nurse & Ward Link Nurse who
have been trained according to WHO 5 Moments Hand Hygiene

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