-IR 2.

0
MINISTRY OF HEALTH
MALAYSIA

e-Incident Reporting System for MoH Malaysia

Hospital / Institution (2023 Update Note)

GUIDE FOR FACILITY QUALITY MANAGER & STATE HEALTH

DEPARTMENT PATIENT SAFETY REPRESENTATIVE 1
e - Incident Report 2.0
MINISTRY OF HEALTH
MALAYSIA

• The first online system for Patient Safety Incident

Report for MoH Hospital e-IR was piloted in 2015.

• The main intention was to provide essential

information of patient safety incidents happening
around the country at almost real-time for
monitoring and action to be taken (national , state and
facility level),
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The 2023 Update
MINISTRY OF HEALTH
MALAYSIA

• The update was done to improve the online reporting

system for Patient Safety Incident Report in MoH
Malaysia Hospital / Institution.
• To reduce numbers of online reporting of “others
category” and to improve the current patient safety
incident taxonomy for MoH Malaysia Hospital /
Institution.

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How will the update impact
the current IR 2.0 system?
• This update is only for the online reporting system of IR 2.0.
This means all the previous policy, guideline , forms and
flow of reporting for IR 2.0 would not be affected.

• This update will only concern Quality Manager of MoH Malaysia

Hospital / Institution ( Penyelaras Kualiti & Keselamatan
Pesakit Hospital ) and person in-charge at State Health Dept.
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How will the update impact
the current IR 2.0 system?

No change in policy , IR 2.0 form , RCA 2.0 Taxonomy changed but

guideline & definition form and PS form most field remains the
remains the same. same 5
Refresher for e-IR 2.0 system :
Who should submit the e-IR 2.0 MINISTRY OF HEALTH
MALAYSIA

online reporting form?

• Only the person appointed by the hospital / facility
(quality & patient safety manager or quality unit )
should send e-IR 2.0 . This is to reduce the issue of
duplication and wrong entry.
• e-IR 2.0 is only for Patient Safety Incident (involves
patient and not staff/other unrelated incidents)
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Refresher for e-IR 2.0 system :
When should it be send?
• Within 5 working day from the incidents.
This is to reduce the problem of information
loss due to late reporting. Refer page 58 of
the ‘Guideline on Implementation – Incident
Reporting & Learning System 2.0 2017’.

Link : https://patientsafety.moh.gov.my/v2/?page_id=60
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Refresher for e-IR 2.0 system : Definition
of actual & near-miss incident
• Patient safety incident: an event or circumstance which could
have resulted, or did result, in unnecessary harm to a patient. An
incident can be a reportable circumstance, near miss, no harm
incident or harmful incident (adverse event).
• Actual Patient Safety Incident:
The incident happen and reach the patient*
• Near miss
The incident did not reach the patient
• *in certain circumstances such as omission error , where planned
medication was not given, this is considered as actual incidents. 8
Refresher for e-IR 2.0 system :
Definition of outcome of incident

• Outcome of patient safety incident in

Incident Reporting & Learning System
2.0 refers to the most likely or actual
outcome that directly related to the
incident. It should not be confused with
the patient current condition or ailment.

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 Pg 20

*In situations where the outcome of an incident can not be weighted by the intervention towards
patient or the increment of length of stay, other factors could be used to determine the severity of
the outcome such as medicolegal implications. 10
Refresher for e-IR 2.0 system : Cases with
high urgency, red-flags or incidents that
directly causes severe or death outcome.

• There are 3 reason where RCA are required :

1. Patient Safety Incident that causes severe or death outcome (directly due to incident)
2. Near-misses that might cause severe or death outcome (directly due to incident)
3. Cases with instruction for RCA from top management due to the high impact / potential
medicolegal.

• In situation where the incident requires immediate attention (high urgency) of

top management at national and state level such as severe or death outcome ,
facility is required to contact Person-in-charge at State Health Dept. and MoH
Patient Safety Unit within 24 hour to alert on the case and take damage control
measures.
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 Flow of Reporting via e-IR 2.0
Send to Quality Manager
within 48H of Incident

Quality manager decide the

Immediate action / Fill in IR 2.0 form (section A) action to be taken and fill in
Patient Safety Incident damage control & Inform Superior* / HOD* section B of IR 2.0

National & state level :

➢ Attention and action for red
flag cases
➢ Cleaning of cases
(duplication and
incomplete/ wrong info).
State level :
➢ Monitor cases and analyse
state data Quality manager send
➢ Take state level action on SHD & MoH received e-IR data details via e-IR 2.0
cases that require attn. within 5 working
12 days
How to access e-IR
2.0 / to report
MINISTRY OF HEALTH
MALAYSIA

incident in e-IR 2.0

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To Report : Step 1

Search “Patient Safety Malaysia” in your preferred search engine and click
on https://patientsafety.moh.gov.my/v2 or directly type in the address.
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To Report : Step 2 (the website)

The website should look like this… 15

To Report : Step 3

OR

Click on this icon at the In the menu, go to [Initiatives] >

frontpage of the website [Incident Report] > click on [e-Incident
Report] 16
To Report : e-IR 2.0 lending
page

Click on your state / facility icon. There are specific icons for HKL , IPR ,
HTA and IKN; these facilities should not report under their state.
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To Report : e-IR 2.0 form

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 To check submission status
for e-IR 2.0
• Every successful submission of e-IR 2.0 will be given a choice to receive an
email copy at the end of the submission. If you receive it, it means it was
successful.
• In situation where email is not received or unsure of status, you can
check the status in [webcheck e-IR 2.0] menu – requires password.
Password for the access to this page will be given by State Health
Dept.
• The page will display only the latest 5 reports received from each state in a
list (non-specific identifiable details will be displayed). 19
To check submission status
for e-IR 2.0

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Patient Safety Incident MINISTRY OF HEALTH

Taxonomy for
MALAYSIA

e-IR 2.0 (2023)

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List of Incidents in e-IR

• There will be a selection of 20 types of incidents in the 2023 update.

• There would not be a selection for other category and if the patient safety incident
does not fit in any of these category, select [Clinical management error ( Investigation
error –includes lab error , diagnostic error, suboptimal treatment / management)]
option and proceed with details or others in the next page. 22
List of Incidents in e-IR
1. Wrong surgery / Procedure
2. Unintended retained surgical item in patient after an operation
3. Unintended retained foreign body in patient after a procedure (procedure other than
operation/ surgery in OT)
4. Error in transfusion of blood / blood products
5. Medication Error
6. Patient Fall in facility
7. Obstetric related incidents
8. Adverse outcome of clinical procedure
9. Pre-hospital care and ambulance service related incident
10. Radiology related incident (Radiotherapy / Imaging)
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 List of Incidents in e-IR
11. Patient suicide / attempted suicide / self-harm
12. Patient discharged to wrong family members / next-of –kin
13. Assault/ battery of patient
14. Unanticipated Fire – Fire, flame, or unanticipated smoke, heat, or flashes occurring in the
facility
15. Clinical management error ( Investigation error –includes lab error , diagnostic error,
suboptimal treatment / management)
16. Other physical injury to patient (excluding assault / battery ) relating to patient safety
17. Dislodgement of catheter / tube
18. Death of patient by unexplained cause or under suspicious circumstances that are
required to be reported to police
19. Missing patient / abduction (NOT ABSCONDED)
20. Food Contamination / Poisoning (not to include patient admitted due to food poisoning) 24
 Details on selection…

• Selection of each type of incidents (except for the last 3 in the list)
will be prompted to fill in additional information (minimal) of the
incident in the next page. This is to make the e-IR2.0 data more
meaningful and to get a rough picture for the situation.

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 Example of Selection for each type of incident

Type of Incident Type of Incident Item

- Wrong surgery / Procedure - URSI - Soft goods (gauze , sponge ,
tampon , swab and etc.)
Type of wrong surgery / procedure Situation - Sharps (needles)
- Wrong Procedure - Cat.1 (retained but decide to leave) - Instruments (Clamp / Scissors
- Wrong Patient - Cat.2 (retained but not found after / Retractor / Depressor / etc.)
- Wrong Site SOP search) - Guidewire / Catheters
- Wrong Side - Cat.3 (incidentally found due to sx. - Small misc. items (broken part
- Wrong Implant or on follow-up) needles / instruments /
others)
Main Factors / Root Cause Main Factors / Root Cause
- Consent - Swab count/instrument count Sub-item
- Patient Identification documentation - Gauze
- Documentation - Swab count/instrument count - Tampon
- Imaging communication - Abdominal pack
- Lab Related - Swab count/instrument count - Instrument / instrument part
- OT Administration (OT list mismatch) procedure - Guide wire
- Other non-compliance to SSSL Procedure - Equipment failure / durability - Catheters
- Others - Skill / experience - Needles
- Others - Others
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 Example of Selection for each type of incident
Type of Incident Item
- URFB (Procedure) - Soft goods (gauze , sponge , tampon , swab Procedure (specify)
and etc.) - Shortline/ longline insertion
Type of URFB - Sharps (needles) (IJC , CVC and etc.)
- Cat.1 (retained but decide to leave) - Instruments (Clamp / Scissors / Retractor / - Vaginal Examination / SVD
- Cat.2 (retained but not found after SOP Depressor / etc.) - Wound dressing
search) - Guidewire / Catheters - Amputation (small)
- Cat.3 (incidentally found due to sx. or on - Small misc. items (broken part needles / - Incision and excision of lump
follow-up) instruments / others) and bump
- Venepuncture / Arterial /
Main Factors / Root Cause Sub-item Branula
- Swab count/instrument count - Gauze - Tubes / drains / catheters
documentation - Tampon - Others
- Swab count/instrument count - Abdominal pack
communication - Instrument / instrument part
- Swab count/instrument count procedure - Guide wire
- Equipment failure / durability - Catheters
- Skill / experience - Needles
- Others - Others

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Example of Selection for each type of incident

Type of Incident Type of Incident

- Error in transfusion of blood / blood products - Medication Error

Type of error Main process for error

- Sampling / labelling error - Prescription
- ABO discrepancy from previous record - Dispensing
- Wrong type of blood product transfused - Administration
- Improper storage & transportation - Omission
- Incorrect blood product issued - Monitoring
- Incorrect blood product provided - Storage and disposal
- Delayed or prolonged transfusion
- Others Type of error
- Wrong Medication
Main Factors / Root Cause - Wrong Patient
- Patient Identification - Wrong Dose
- Non compliance to blood taking SOP - Wrong Time
- Documentation Error - Wrong Route
- Laboratory Technical Error - Wrong Indication
- Others - Wrong Documentation

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 Example of Selection for each type of incident
Type of Incident
- Patient Fall in facility Main Factors / Root Cause
- Medical condition
Location - Wet floor
- Corridor / hallway - Wheel not secure / moving parts not secure
- Nursing station - Railing malfunction or absent or not used
- Toilet / near-toilet - Tired / sleepy / lapse of concentration
- Bed / Bed-side / baby cot - Others
- Pantry / Dining area / Common area
- Treatment room
- OT area
- Stairs
- High floor edge / ledge

Situation
- Chair / Wheelchair
- Transferring patient / stretcher / trolley
- While holding / breastfeeding
- During therapy
- Manoeuvring walking aid
- Reaching out
- Slipped
- Loss of balance
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- Others
 Example of Selection for each type of incident
Type of Incident Type of Incident
- Obstetric related incidents - Adverse outcome of clinical procedure

Incidents involving Type of adverse outcome

- Mother - Extravasation of fluid / medication / contrast
- Baby - Thrombophlebitis
- Both - Pneumothorax / Haemothorax
- Perforation of organs
Type of Obs. incident - Oral injury (Intubation related complication & etc.)
- PPH / Uterine atony - Nerve and blood vessels injury
- Perineal tear (3rd degree tear and above only) - High spinal anaesthesia
- Cervical tear - Aspiration
- Vaginal and surrounding area haematoma - Others
- Shoulder dystocia
- Laceration wound on baby Procedure
- Neonatal bone fracture - Venepuncture / Arterial line
- SAH - Tubes / catheter / drain insertion
- HIE - Intravenous fluid / medication / contrast
- Nerve injury - Intubation
- Delivery other than labour room - LSCS
- Placenta abruptio - Scope procedure
- Cord prolapse - Anaesthesia
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- Others (specify) - Others
Example of Selection for each type of incident
Type of Incident Type of Incident
- Pre-hospital care and ambulance service - Radiology related incident (Radiotherapy /
related incident Imaging)

Level of care Type of incident

- Before transfer - Wrong imaging
- During transfer - Wrong labelling
- Receiving case - Wrong patient
- Wrong side / site
Situation - Wrong report
- Inadequate assessment / stabilization - Delayed imaging
- Inadequate / improper monitoring - Delayed report
- Inadequate preparation of medication and - Incomplete imaging
equipment - Pregnant patient (not known)
- Road traffic accident - Exposed to other patient
- Physical injury (bumps / lacerations / etc. ) - Repeated imaging in close interval
- Vehicle problem - Unnecessary imaging
- Wrong identification / documentation - Others
- Wrong destination
- Others
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Example of Selection for each type of incident

Type of Incident Type of Incident

- Patient suicide / attempted suicide / self-harm - Patient discharged to wrong family members /
next-of –kin
Type of suicide incident
- Hanging Sub-Type
- Strangulation - Adult
- Jump from height - Paediatric (<12)
- Poison / Medication
- Self inflicted physical injury using sharp / blunt Main Factors / Root Cause
object / wall - Wrong identification
- Wrong documentation
- Abduction /Criminal intention
- Others

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 Example of Selection for each type of incident
Type of Incident Situation
- Unanticipated Fire – Fire, flame, or - Wire trip
unanticipated smoke, heat, or flashes - Equipment related
occurring in the facility - Lightings / fan / plug / switch /
Type of Incident other inbuild electrical components
Location - Oxygen outlet
- Assault/ battery of patient - Ward - Cigarette / vape related
- Emergency - Intentional
Location - High dependency ward / ICU / PICU or - Patient related appliance /
- Inpatient similar equipment
- Out patient - Store near patients area
- Clinics / outpatient services area
- Pantry / Dining area / Common area
Situation
- Treatment room
- Patient to Patient
- Staff to Patient Types
- Relative or Others to Patient - Actual fire
- Explosion
- Spark
- Flash
- Smoke
- Heat

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Type of Incident
- Clinical management error ( Investigation error –
includes lab error , diagnostic error, suboptimal
treatment / management )

Process involved in error (most significant or likely) Factor

• Patient Assessement and Examination - Lab Related Error
• Investigation
• Diagnosis Sub-classification
• Treatment & Management - Delay in processing sample
- Delay result and critical value
Situation
- Labelling and sampling
- Unplanned readmission to A&E / OT / ICU - Lab Result Error
- Unplanned cessation of treatment / support - Documentation Error
- Wrong management (investigation, diagnosis, - Sample Rejection / Sample Missing
treatment , referral and etc.)
- Delay in management (investigation, diagnosis,
treatment , referral and etc.)

Main Factors / Root Cause

- Laboratory Related Error
- Equipment malfunction / misuse
- Documentation error
- Identification error
- Miscommunication
- Skill / experience / competency
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- Others
 Example of Selection for each type of incident

Type of Incident
- Dislodgement of catheter / tube
Type of Incident
- Other physical injury related to patient safety Types of dislodgement
- ETT (including self extubation)
Sub-classification - Chest Tube
- Thermal Burn injury (Diathermy / Hot Packing) - Epidural catheter
- Chemical Burn Injury (Chemical leak / spillage) - Venous / Arterial Cannula
- Radiation Burn Injury - Tracheostomy tube
- Electric Shock / Burn - Haemodialysis cath. tube
- Physical injury due to structure / building - T-connector
- Sharp injury - Long / Short Line
- Others - Ryle’s tube
- Urinary catheter
- Others

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Example of Selection for each type of incident

Type of Incident
- Death of patient by unexplained cause or
under suspicious circumstances that are
required to be reported to police

Type of Incident
- Missing patient / abduction (NOT
ABSCONDED)

Type of Incident
- Food Contamination / Poisoning

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 MINISTRY OF HEALTH
MALAYSIA

THANK YOU
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