e-IR REPORT
JULY- DECEMBER 2015
By:
Dr. Nor ‘Aishah Abu Bakar
Dr. Khairulina Haireen Khalid
Dr. Ahmad Muzammil Abu Bakar
Mrs Sharmila Mat Zain
PATIENT SAFETY UNIT
MEDICAL CARE QUALITY SECTION
MEDICAL DEVELOPMENT DIVISON
MINISTRY OF HEALTH MALAYSIA
INTRODUCTION
The Ministry of Health Malaysia (MoH) Incident Reporting &
Learning System was first introduced in 1999. It was
developed as one of the tool to provide information on
patient safety incidence and at the same time maintaining
confidentiality in healthcare organisation.
Currently, there are 29 mandatory reportable incidents for
hospitals. In March 2015, the Director General of Health
Malaysia, YBhg. Datuk Dr. Noor Hisham Abdullah has
launched an online system called e-IR (e-Incident Reporting).
The main objectives are to enhance reporting in hospital
through a more user friendly system and to decrease the
burden of hospitals/ State Health Departments by eliminating
the matrix system. e-IR also allows for more precise and detail
analysis of the incidents.
INTRODUCTION (CONT’D)
“Director General of Health Circular No.2/2016: Incident
Reporting in Hospital and Medical Institutions in Ministry of
Health Using e-IR System And The Use of Standardised
Format For RCA Report” formally authorized the use of eIR and standardised format for RCA Report starting from
January 2016 in all MoH Hospitals/ Medical Institutions.
This report is based on the analysis of e-IR data from the
pilot project conducted in July-December 2015. The
coding used in this report is based on “MoH Incident
Reporting & Learning System Manual 2013”.
TOTAL NUMBER OF REPORTING
JULY –DEC 2015
7
8
TOTAL NUMBER OF REPORTING
(MANDATORY) BASED ON CASE
CATEGORY
7
Yellow, 61,
12%
mandatory
516
voluntary
271
Total number
of reporting
Note: only mandatory incidents were included for
detailed analysis
Red, 142,
27%
Green, 313,
61%
NUMBER OF HOSPITALS WITH STATUS OF e-IR
REPORTING JULY-DEC 2015
1
1
5
8
4
1
1
3
5
Labuan
3
5
7
2
10
5
6
7
6
10
3
2
2
4
1
3
9
17
13
2
Number of hospital which report via
e-ir
Number of hospital which did not
report via e-ir
NUMBER OF INCIDENTS BY
MONTH JULY-DEC 2015
112
96
100
100
61
47
Jul
Aug
*Note: only mandatory incidents were included for detailed analysis
Sep
Oct
Nov
Dec
NUMBER OF INCIDENTS BY STATE
JULY- DEC 2015
110
66
60
32
30
24
20
*Note: only mandatory incidents were included for detailed analysis
JOHOR
P.PINANG
PERAK
KEDAH
N9
SABAH
PERLIS
WPKL
MELAKA
PAHANG
SARAWAK
SELANGOR
11
10
4
3
1
KELANTAN
32
TERENGGANU
35
LABUAN
37
PUTRAJAYA
39
NUMBER OF INCIDENTS BY STATE
AND CASE CATEGORY
JULY-DEC 2015
Red
Yellow
Green
58
43
40
35
27
25
20
24
22
21
22
18
15
*Note: only mandatory incidents were included for detailed analysis
8
1
KELANTAN
3
TERENGGANU
3
1
LABUAN
1
7
4
JOHOR
1
5 4
3
PUTRAJAYA
WPKL
8
2
PERLIS
2
1
MELAKA
PAHANG
SARAWAK
SELANGOR
3
8
P.PINANG
6
12
11
10
PERAK
9
KEDAH
10
N9
11
SABAH
12
NUMBER OF INCIDENTS BY THE
HOUR JULY DEC 2015
48
43
38
34
28
30
30
25
20
26
23
20
17
11
12
12
10
13
11
14
16
15
12
8
12 AM 1 AM 2 AM 3 AM 4 AM 5 AM 6 AM 7 AM 8 AM 99AM
AM 10 AM 11 AM 12 PM 1 PM 2 PM 3 PM 4 PM 5 PM 6 PM 7 PM 8 PM 9 PM 10 PM 11 PM
*Note: only mandatory incidents were included for detailed analysis
NUMBER OF INCIDENTS BY CODE
JULY-DEC 2015
130
TOP 5 HIGHEST
INCIDENTS
CODE 21
CODE 26
CODE 3b
CODE 17
CODE 1
69
55
46
37
35
19
15
21
26
3b
17
1
24
13
22
14
9
12
25
11
3c
*Note: only mandatory incidents were included for detailed analysis
11
19
9
16
9
27
6
18
6
5
5
20
5
2
5
6
5
7
2
2
2
1
1
1
1
3a
12
15
29
28
23
14
21
3
1
1
1
1
WPKL
PUTRAJAYA
LABUAN
2
JOHOR
PERLIS
SARAWAK
P.PINANG
PERAK
16
SELANGOR
KEDAH
N9
SABAH
MELAKA
NUMBER OF CODE 21 INCIDENTS
BY STATE JULY-DEC 2015
32
22
19
16
9
7
NUMBER OF CODE 21 INCIDENTS
BY HOSPITAL JULY-DEC 2015
32
20
18
15
11
9
4
2
I1
N21
H6
B3
E5
D5
C6
E6
2
E4
2
C2
*Note: only mandatory incidents were included for detailed analysis
2
A1
1
1
1
1
1
J9
P21
P20
P11
O1
HOSPITAL CODE
1
1
N20 N19
1
1
1
1
1
1
H5
G1
F1
E10
C5
B4
NUMBER OF CODE 26 INCIDENTS BY
STATE/ HOSPITAL JULY-DEC 2015
33
15
1
PUTRAJAYA
JOHOR
PERAK
4
2
WPKL
3
KEDAH
5
SARAWAK
SELANGOR
PERLIS
7
20
15
9
5
E2
A1
E4
D5
4
E5
4
F1
3
J1
3
P4
HOSPITAL CODE
2
G1
1
1
1
1
1
B5
P21
P20
p8
p14
*Note: only mandatory incidents were included for detailed analysis
NUMBER OF CODE 3B INCIDENTS –
BY STATE/ HOSPITAL JULY-DEC 2015
11
11
6
4
4
4
4
3
3
2
SELANGOR
SARAWAK
WPKL
N9
KEDAH
P.PINANG
PERAK
PUTRAJAYA
SABAH
PAHANG
1
1
1
KELANTAN
PERLIS
MELAKA
3b
7
5
5
4
3
3
2
2
2
2
2
1
P21 E6
F1 P23 H6
E5
B4
E4
C2 N21 G1 B3
*Note: only mandatory incidents were included for detailed analysis
1
1
B2 M9
1
1
1
1
I1
H4
k4
K1
HOSPITAL CODE
1
1
1
1
1
1
1
1
1
1
1
D2 D15 D13 D8 A1
C6
C5 N15 E2
F2
G2
NUMBER OF CODE 24 INCIDENTS
BY STATE JULY-DEC 2015
9
9
7
3
2
SARAWAK
PERLIS
SELANGOR
KEDAH
PERAK
24
*Note: only mandatory incidents were included for detailed analysis
2
SABAH
1
1
1
JOHOR
WPKL
PAHANG
NUMBER OF CODE 24 INCIDENTS BY
HOSPITAL JULY-DEC 2015
9
6
4
2
A1
P21
E4
B3
2
D5
2
P15
2
E8
1
1
1
1
1
1
1
1
J9
B4
k10
N12
N19
P18
E5
F1
HOSPITAL CODE
NUMBER OF CODE 13 INCIDENTS
BY STATE/ HOSPITAL JULY-DEC
2015
5
4
3
KEDAH
PAHANG
N9
JOHOR
SARAWAK
SELANGOR
1
1
1
SABAH
2
P.PINANG
2
3
2
P18
J1
2
E4
2
k10
2
E10
1
1
1
1
1
1
1
1
J9
B6
H6
H3
C2
N1
P20
E6
HOSPITAL CODE
*Note: only mandatory incidents were included for detailed analysis
NUMBER OF CODE 9 INCIDENTS
BY STATE/ HOSPITAL JULY-DEC
2015
5
3
2
SELANGOR
N9
WPKL
1
1
1
1
SARAWAK
MELAKA
P.PINANG
PERLIS
9
3
2
H6
E10
2
F1
1
1
1
1
1
1
1
I1
A1
C5
P20
E2
E6
E5
*Note: only mandatory incidents were included for detailed analysis
NUMBER OF CODE 3C INCIDENTS
BY STATE/ HOSPITAL JULY-DEC 2015
3
3
2
SELANGOR
SARAWAK
JOHOR
1
1
1
MELAKA
PUTRAJAYA
PAHANG
3c
2
J1
2
E4
1
1
1
1
1
1
1
I2
K3
P21
P18
P15
E6
G1
HOSPITAL CODE
NUMBER OF CODE 19 INCIDENTS
BY STATE/ HOSPITAL JULY-DEC
2015–
3
2
SABAH
2
SARAWAK
SELANGOR
1
1
1
1
WPKL
PERAK
P.PINANG
KEDAH
19
2
E4
1
1
1
1
1
1
1
1
1
B4
D5
C6
N21
N15
N12
P11
P15
F1
*Note: only mandatory incidents were included for detailed analysis
NUMBER OF CODE 17 & CODE 1
INCIDENTS JULY-DEC 2015
CODE 17
CODE 16
Unplanned Return To OT
HOSPITALWithin
CODE 24 H NUMBER
OF CASE
of Surgery
CODE 1
HOSPITAL CODE
NUMBER OF CASE
B3
1
E4
2
I1
2
H5
1
K1
37
A1
1
K5
1
p11
2
K10
2
E9
2
C5
1
N22
1
E5
1
P21
1
O1
2
P15
2
TOTAL
46
E8
1
E6
1
E5
3
L2
1
F1
14
O1
1
G1
3
TOTAL
37
*Note: only mandatory incidents were included for detailed analysis
NUMBER OF CODE 22 & CODE 25
INCIDENTS JULY-DEC 2015
CODE 25
CODE 22
HOSPITAL CODE
NUMBER OF CASE
B3
1
I1
2
K10
1
C2
HOSPITAL CODE
NUMBER OF CASE
K5
1
A1
3
2
p11
1
C5
1
P20
2
P21
5
E5
1
E10
1
E5
1
F1
4
G1
1
G1
1
TOTAL
15
TOTAL
13
*Note: only mandatory incidents were included for detailed analysis
NUMBER OF CODE 16 & CODE 27
INCIDENTS JULY-DEC 2015
CODE 16
HOSPITAL CODE
CODE 27
NUMBER OF CASE
HOSPITAL CODE
NUMBER OF CASE
C5
1
E4
1
P16
1
A1
3
E5
4
P11
1
F1
3
E2
1
TOTAL
9
E9
1
L2
2
TOTAL
9
*Note: only mandatory incidents were included for detailed analysis
NUMBER OF CODE 18 & CODE 5
INCIDENTS JULY-DEC 2015
SENTINEL EVENTS
SENTINEL EVENTS
CODE 5
CODE 18
HOSPITAL CODE
NUMBER OF CASE
HOSPITAL CODE
NUMBER OF CASE
B3
1
E4
3
B4
1
P21
3
H3
1
TOTAL
6
D5
1
P21
2
TOTAL
6
*Note: only mandatory incidents were included for detailed analysis
NUMBER OF CODE 20 & CODE 2
INCIDENTS JULY-DEC 2015
SENTINEL EVENTS
CODE 20
HOSPITAL CODE
CODE 2
NUMBER OF CASE
HOSPITAL CODE
NUMBER OF CASE
J4
1
K10
3
H6
1
E8
1
K10
3
E5
1
TOTAL
5
TOTAL
5
*Note: only mandatory incidents were included for detailed analysis
NUMBER OF CODE 6 & CODE 7
INCIDENTS JULY-DEC 2015
SENTINEL EVENTS
SENTINEL EVENTS
CODE 6
HOSPITAL CODE
CODE 7
NUMBER OF CASE
HOSPITAL CODE
NUMBER OF CASE
K10
2
E4
1
P21
3
K10
1
TOTAL
5
P21
1
E6
1
F1
1
TOTAL
5
*Note: only mandatory incidents were included for detailed analysis
NUMBER OF CODE 3A & CODE 12
INCIDENTS JULY-DEC 2015
SENTINEL EVENTS
SENTINEL EVENTS
CODE 3a
HOSPITAL CODE
CODE 12
NUMBER OF CASE
HOSPITAL CODE
NUMBER OF CASE
D5
1
K10
1
P21
1
D5
1
TOTAL
2
TOTAL
2
*Note: only mandatory incidents were included for detailed analysis
NUMBER OF CODE 15 & CODE
28 INCIDENTS JULY-DEC 2015
SENTINEL EVENTS
SENTINEL EVENTS
CODE 15
HOSPITAL CODE
CODE 28
NUMBER OF CASE
HOSPITAL CODE
NUMBER OF CASE
C6
1
K10
1
P15
1
TOTAL
1
TOTAL
2
*Note: only mandatory incidents were included for detailed analysis
NUMBER OF CODE 29 & CODE 23
INCIDENTS JULY-DEC 2015
SENTINEL EVENTS
CODE 29
HOSPITAL CODE
CODE 23
NUMBER OF CASE
HOSPITAL CODE
NUMBER OF CASE
K4
1
E5
1
TOTAL
1
TOTAL
1
*Note: only mandatory incidents were included for detailed analysis
NUMBER OF CODE 14 INCIDENT
JULY-DEC 2015
SENTINEL EVENTS
CODE 14
HOSPITAL CODE
NUMBER OF CASE
H6
1
TOTAL
1
*Note: only mandatory incidents were included for detailed analysis
SUMMARY
1. Total number of reporting from July - December 2015
was 787 cases. 516 cases of them were ‘mandatory’
reportable cases while 271 cases were ‘voluntary’
reportable cases.
2. Of all 146 MoH hospitals, only 59 hospitals (40%) reported
their incidents via e-IR.
3. Only 11% of hospitals in Kelantan, 16% in Terengganu,
25% in Johor and 29% in Sabah reported their incidents
via e-IR.
4. e-IR seems to be implemented mostly in Selangor,
Sarawak & Pahang.
5. Under reporting is still an issue in many states.
6. Reporting was highest in July (112 incidents), September
(100 incidents) and October (100 incidents).
SUMMARY (CONT’D)
7. In terms of timing, most incidents happened between 8
am to 11 am with total of 163 incidents (32% of all
incidents). The possibilities are:
• More incidents happened during busy hours
• Reporting is better at this time due to better
supervision
8. Less incidents happened after ‘office hour’.
9. The top 5 most incidents reported are incidents with
code:
• Code 21 (130 incidents)
• Code 26 (69 incidents)
• Code 3b (55 incidents)
• Code 17 (46 incidents)
• Code 1 (37 incidents)
10.The highest sentinel events was Code 3b with 55
incidents.
WAY FORWARD
1. Technical Working Group on Malaysian Patient
Safety Goals No.13: To Implement An Incident
Reporting & Learning System has been established
at national level to improve MoH Incident
Reporting & Learning System.
2. Closer supervision is needed to improve incident
reporting by State Health Departments.
3. Training to improve formulation of action plan,
implementation & monitoring of outcome need to
be provided at facility level to healthcare staffs.