The Patient Safety Incident Reporting Form is a crucial document used across Malaysian healthcare facilities to maintain comprehensive records of patient safety incidents and ensure regulatory compliance. This form is designed in accordance with Malaysian healthcare legislation, including the Private Healthcare Facilities and Services Act 1998 and the Guidelines on Patient Safety Incident Reporting and Learning System 2013. It serves as an essential tool for healthcare providers to document adverse events, near-misses, and other patient safety concerns, facilitating systematic analysis and continuous improvement of healthcare services. The form supports healthcare facilities in meeting their legal obligations for incident reporting while contributing to the broader goal of enhancing patient safety and quality of care in Malaysia's healthcare system.
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1. Reporter Information: Details of the person reporting the incident, including name, position, department, and contact information
2. Patient Information: Basic demographic and medical information of the affected patient, including ID number, age, gender, and relevant medical condition
3. Incident Details: Core information about the incident including date, time, location, and type of incident
4. Incident Description: Detailed narrative of what happened, including sequence of events and immediate actions taken
5. Severity Assessment: Classification of incident severity using standardized risk assessment matrix
6. Immediate Actions Taken: Description of steps taken immediately after the incident to ensure patient safety and minimize harm
7. Notifications Made: Record of who was notified about the incident (e.g., supervisor, physician, family)
8. Initial Impact Assessment: Evaluation of the impact on the patient, staff, and organization
9. Declaration: Confirmation of accuracy and completeness of the report, with reporter's signature and date
1. Witness Information: Details of any witnesses to the incident, used when witnesses were present
2. Equipment Details: Information about any medical equipment involved in the incident, used when equipment malfunction or misuse is part of the incident
3. Medication Details: Specific information about medications involved, used for medication-related incidents
4. Contributing Factors: Analysis of factors that may have contributed to the incident, used for complex incidents requiring detailed analysis
5. Patient/Family Response: Documentation of patient or family reactions and communications, used when direct patient/family interaction occurred
6. Staff Injury Details: Information about any staff injuries, used when staff members were also affected by the incident
1. Risk Assessment Matrix: Standard matrix for assessing incident severity and likelihood
2. Incident Classification Guide: Reference guide for categorizing different types of incidents
3. Notification Protocol: Guidelines on who should be notified based on incident type and severity
4. Follow-up Action Checklist: Standard checklist for required follow-up actions based on incident type
5. Reporting Timeframe Guidelines: Reference guide for mandatory reporting timeframes based on incident severity
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