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Patient Safety Incident Reporting Form

Patient Safety Incident Reporting Form Template for Malaysia

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Key Requirements PROMPT example:

Patient Safety Incident Reporting Form

"I need a Patient Safety Incident Reporting Form for my private dental clinic in Kuala Lumpur that's simplified for a small practice setting but still compliant with Malaysian healthcare regulations, with particular focus on dental-specific incidents and procedures."

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Document background
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.
Suggested Sections

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

Optional Sections

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

Suggested Schedules

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

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Linkedin in social icon imageX social icon image
alex.den.21@genieai.co
Relevant Industries

Healthcare

Hospital Services

Primary Care

Aged Care

Mental Health Services

Emergency Medical Services

Rehabilitation Services

Diagnostic Services

Pharmaceutical Services

Allied Health Services

Relevant Teams

Quality Assurance

Risk Management

Clinical Operations

Patient Safety

Nursing Administration

Medical Administration

Compliance

Legal

Clinical Governance

Emergency Services

Ward Management

Relevant Roles

Medical Director

Hospital Administrator

Chief Medical Officer

Quality Assurance Manager

Risk Management Officer

Patient Safety Officer

Nurse Manager

Clinical Department Head

Healthcare Facility Manager

Compliance Officer

Medical Officer

Registered Nurse

Pharmacist

Allied Health Professional

Emergency Department Physician

Ward Supervisor

Clinical Quality Coordinator

Industries
Private Healthcare Facilities and Services Act 1998: Sets standards for private healthcare facilities and services, including requirements for incident reporting and patient safety measures
Medical Act 1971: Governs medical practice in Malaysia and establishes professional standards for healthcare providers, including their responsibilities in reporting adverse events
Personal Data Protection Act 2010: Regulates the collection, storage, and handling of personal data, including sensitive medical information in incident reports
Quality in Medical Care Section 1998: Ministry of Health guidelines for quality assurance in healthcare, including incident reporting protocols
Malaysian Patient Safety Goals: National guidelines establishing patient safety objectives and reporting requirements for healthcare facilities
Guidelines on Patient Safety Incident Reporting and Learning System 2013: Specific guidelines from the Ministry of Health Malaysia on how to report and learn from patient safety incidents
Occupational Safety and Health Act 1994: Relevant for incidents that may also affect healthcare workers and workplace safety requirements
Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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