Page 33 - MALAYSIAN PATIENT SAFETY GOALS

TECHNICAL SPECIFICATIONS OF MALAYSIAN PATIENT SAFETY GOALS & KPIs
rd
Patient Safety To implement the WHO’s 3 Global Patient Safety Challenges-
Goal No. 4 “Tackling Antimicrobial Resistance”
Rationale Antimicrobial resistance poses a growing threat to the treatment
and control of infections.
Strategies & 1. The Malaysian National Antibiotic Guidelines are implemented.
Implementation 2. National and State Campaign on Containment of Antimicrobial
Resistance
3. Antibiotic Stewardship Programme

KPI No. 5 Incidence Rate Of MRSA Infection

Numerator (N) Number of patients with MRSA infection in the hospital
Denominator (D) Total number of hospital admissions
Formula (N/D) x 100
Target ≤0.4%
KPI No. 6 Incidence Rate Of ESBL- Klebsiella pneumonia Infection
Numerator (N) Number of patients with ESBL- Klebsiella pneumoniae infection in the
hospital
Denominator (D) Total number of hospital admissions
Formula (N/D) x 100
Target ≤0.3%
KPI No. 7 Incidence Rate Of ESBL- E.coli Infection
Numerator (N) Number of patients with ESBL- E.coli infection in the hospital
Denominator (D) Total number of hospital admissions
Formula (N/D) x 100
Target ≤0.2%
Definition of Case definitions:
Terms MDRO (Multi-Drug Resistant Organisms) case definition must fulfill ALL of
the following criteria:
1)Isolation of an MDRO from any body sites
2)The patient must be admitted to the ward
3)The case must be “Newly Identified”
“Newly Identified” include:
I.MDRO identified for the first time during current hospital admission
II.Cases that have been identified at your site but acquired “new infection”
(infection with organism having different antibiogram or defined as new
infection by the attending clinician)
Population under surveillance is all in-patients - Exclusion:
1)Cases from Emergency department, clinic or other outpatient services
2)Cases previously identified at other acute care facilities/hospitals
3)Cases re-admitted with same alert organisms within one year
4)Cases with insufficient information on healthcare exposure
5)Cases from screening culture
6)Coloniser

Data collection at Monthly
facility level
Reference Alert Organism Surveillance Manual, Ministry Of Health 2012

32