Page 40 - MALAYSIAN PATIENT SAFETY GOALS

TECHNICAL SPECIFICATIONS OF MALAYSIAN PATIENT SAFETY GOALS & KPIs

Patient Safety To improve the accuracy of patient identification
Goal No. 5

Rationale Patient identification is essential step in ensuring that the
correct treatment is being given to the correct patient.

Strategies & To implement the use of at least two identifiers for a patient

implementation at point of providing care, treatment or health services.

KPI No. 8 Compliance Rate For “At Least 2 Identifiers Implemented”
(refer page 41)

Definition of • Patient identifier: person-specific information, not
the medium on which that information resides
Terms
• The opportunity: is an accounting unit for the
action; it determines the need to perform or observe
process of patient identification at point of providing

care, treatment or health services
“Acceptable method of Identification”:Patient’s name,
patient’s tag, registration number (RN), NRIC and date of
birth
“Unacceptable method of Identification”:Patient’s room
number or patient’s bed number

x upon admission or transfer/ transport to another
Examples of
hospital or other care setting
processes
x administration of all medicines
/procedures
x X- ray or imaging procedures
requiring patient x Surgical intervention or procedures

identification x Blood transfusion or blood products
x Collecting of patient’s bodily fluid samples
x Confirmation of death

Numerator (N) Number of process whereby at least 2 identifiers are being
used

Denominator (D) Number of opportunities observed
Formula (N/D) x 100

Target 100% compliance rate at each audit
Data collection at 6 monthly

facility level

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