e-goals Patient Safety (TEST SHORT)
**ATTENTION : THIS FORM IS ONLY FOR TESTING

INSTRUCTIONS

1) Use CAPITAL LETTER when you fill in this form.
(Sila guna HURUF BESAR ketika mengisi borang ini.)

2) Once completed, PLEASE REVIEW the data given as the data cannot be saved or retrieved once it has been sent to the Technical Secretariat of Patient Safety Council Malaysia.
(Setelah selesai mengisi, SILA SEMAK data yang diberikan kerana data tidak boleh disimpan atau dicapai semula oleh pihak anda setelah dihantar kepada Sekretariat Teknikal Majlis Keselamatan Pesakit Malaysia.)

3) This "e-goals: patient safety" form must be submitted via the online form by 31st JANUARY EVERY YEAR.
(Borang "e-goals: patient safety " ini mesti dihantar mengunakan borang atas talian ini pada 31 JANUARI SETIAP TAHUN)

4) Any inquiry, please call Technical Secretariat of Patient Safety Council Malaysia (03-88831180 / 1196 / 1199) at Patient Safety Unit, Medical Care Quality Section, Medical Development Division, Ministry of Health Malaysia.
(Sebarang pertanyaan, sila hubungi Sekretariat Teknikal Majlis Keselamatan Pesakit Malaysia (03-88831180/ 1196 / 1199) di Unit Keselamatan Pesakit, Cawangan Kualiti Penjagaan Perubatan, Bahagian Perkembangan Perubatan, Kementerian Kesihatan Malaysia)

Thank you for your cooperation and we appreciate your effort in submitting the data.
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KINDLY PROVIDE ACCURATE E-MAIL ADDRESS OF PERSON IN-CHARGE BELOW (AVOID GIVING moh.gov.my / official EMAIL ACCOUNT TO AVOID PROBLEM IN RECEIVING SUMMARY OF RESPONSE AFTER FORM SUBMISSION). THIS E-MAIL ADDRESS WILL BE USED TO GIVE AN AUTOMATIC RESPOND UPON SUBMISSION OF THE FORM AND TO GIVE A SUMMARY OF THE DATA FILLED.

SILA BERI ALAMAT EMEL PEGAWAI YANG BERTANGGUNGJAWAB DIBAWAH (ELAKKAN DARIPADA MENGGUNAKAN EMEL moh.gov.my / email rasmi KERANA EMEL MAKLUMBALAS PENGHANTARAN MUNGKIN DISEKAT MELALUI EMEL INI). EMEL INI AKAN DIGUNAKAN BAGI MEMBERIKAN MAKLUMBALAS AUTOMATIK SELEPAS PENGHANTARAN BORANG INI.
Email address *
STATE *
Select relevant state for your facility. Make sure you have selected the correct option before proceeding to the next question.
NAME OF FACILITY *
Type in full name and in CAPITAL LETTER. E.g. 1 : HOSPITAL KUALA LUMPUR / E.g 2 : KLINIK KESIHATAN BATU / E.g. 3 : KLINIK PERGIGIAN BARU 1
Your answer
PEJABAT KESIHATAN DAERAH
SKIP THIS IF NOT APPLICABLE. Type in full name and in CAPITAL LETTER. Example : PKD HULU LANGAT , PKK KINABALU , PKB BINTULU
Your answer
TYPE OF FACILITY *
YEAR OF REPORT *
Year of performance report
TYPE OF ORGANIZATION *
TOTAL NUMBER OF PATIENT ADMISSION (FOR HOSPITAL) OR PATIENT VISIT (FOR CLINICS) FOR 2016 *
Input the total number of PATIENT ADMISSION (FOR HOSPITAL) OR PATIENT VISIT (FOR CLINICS) for 2016. Enter the TOTAL NUMBER ONLY, not the percentage or ratio. IF DATA NOT AVAILABLE ANSWER AS ( ND ) CODE FOR NO DATA.
Your answer
Goal 1 : Do you implement Clinical Governance? *
Goal 7.1 : Total Number of Medication Error (ACTUAL) *
KINDLY ANSWER THE TOTAL NUMBER OF ACTUAL MEDICATION ERROR CASES ( E.g. : 312 , IF YOU HAVE 312 CASES ) NOT PERCENTAGE OR RATIO. IF YOUR FACILITY DID NOT IMPLEMENT THE GOAL, ANSWER AS ( NI ) CODE FOR NOT IMPLEMENTING. IF DATA NOT AVAILABLE ANSWER AS ( ND ) CODE FOR NO DATA AND IF IT IS NOT APPLICABLE ANSWER AS ( NA ) CODE FOR NOT APPLICABLE.
Your answer
Goal 7.2 : Total Number of Medication Error (NEAR MISS) *
KINDLY ANSWER THE TOTAL NUMBER OF NEAR MISS MEDICATION ERROR CASES ( E.g. : 312 , IF YOU HAVE 312 CASES ) NOT PERCENTAGE OR RATIO. IF YOUR FACILITY DID NOT IMPLEMENT THE GOAL, ANSWER AS ( NI ) CODE FOR NOT IMPLEMENTING. IF DATA NOT AVAILABLE ANSWER AS ( ND ) CODE FOR NO DATA AND IF IT IS NOT APPLICABLE ANSWER AS ( NA ) CODE FOR NOT APPLICABLE.
Your answer
Total Number of Medication Prescribed in 2016 *
Give total number of medication prescribed in 2016 ( e.g : 10592 , If your facility prescribe 10,592 medication to patient in 2016 ). IF DATA NOT AVAILABLE ANSWER AS ( ND ) CODE FOR NO DATA AND IF IT IS NOT APPLICABLE ANSWER AS ( NA ) CODE FOR NOT APPLICABLE.
Your answer
Goal 9.1 : Adult Patient Fall Prevention (Total Number of Adult Patient Fall in 2016) *
KINDLY ANSWER THE TOTAL NUMBER OF ADULT PATIENT FALL CASES IN 2016 ( E.g. : 3 , IF YOU HAVE 3 CASES ) FOR 2016 NOT PERCENTAGE OR RATIO. IF YOUR FACILITY DID NOT IMPLEMENT THE GOAL, ANSWER AS ( NI ) CODE FOR NOT IMPLEMENTING. IF DATA NOT AVAILABLE ANSWER AS ( ND ) CODE FOR NO DATA AND IF IT IS NOT APPLICABLE ANSWER AS ( NA ) CODE FOR NOT APPLICABLE.
Your answer
Goal 9.1 : Adult Patient Fall Prevention (Total Number of Adult Patient Fall in 2015) *
FOR US TO CALCULATE THE PERCENTAGE OF REDUCTION OF FALL. KINDLY ANSWER THE TOTAL NUMBER OF ADULT PATIENT FALL CASES IN 2015 ( E.g. : 3 , IF YOU HAVE 3 CASES ) FOR 2016 NOT PERCENTAGE OR RATIO. IF YOUR FACILITY DID NOT IMPLEMENT THE GOAL, ANSWER AS ( NI ) CODE FOR NOT IMPLEMENTING. IF DATA NOT AVAILABLE ANSWER AS ( ND ) CODE FOR NO DATA AND IF IT IS NOT APPLICABLE ANSWER AS ( NA ) CODE FOR NOT APPLICABLE.
Your answer
Goal 9.2 : Paediatric (12y.o and below) Patient Fall Prevention (Total Number of Paediatric Patient Fall in 2016) *
KINDLY ANSWER THE TOTAL NUMBER OF PAEDIATRIC PATIENT FALL CASES FOR 2016 ( E.g. : 3 , IF YOU HAVE 3 CASES ) NOT PERCENTAGE OR RATIO. THIS DOES NOT INCLUDE NON INJURIOUS DEVELOPMENT FALL FOR INFANTS/ TODDLERS AS THEY ARE LEARNING TO WALK. IF YOUR FACILITY DID NOT IMPLEMENT THE GOAL, ANSWER AS ( NI ) CODE FOR NOT IMPLEMENTING. IF DATA NOT AVAILABLE ANSWER AS ( ND ) CODE FOR NO DATA AND IF IT IS NOT APPLICABLE ANSWER AS ( NA ) CODE FOR NOT APPLICABLE.
Your answer
Goal 9.2 : Paediatric (12y.o and below) Patient Fall Prevention (Total Number of Paediatric Patient Fall in 2015) *
FOR US TO CALCULATE THE PERCENTAGE OF REDUCTION OF FALL. KINDLY ANSWER THE TOTAL NUMBER OF PAEDIATRIC PATIENT FALL CASES FOR 2015 ( E.g. : 3 , IF YOU HAVE 3 CASES ) NOT PERCENTAGE OR RATIO. THIS DOES NOT INCLUDE NON INJURIOUS DEVELOPMENT FALL FOR INFANTS/ TODDLERS AS THEY ARE LEARNING TO WALK. IF YOUR FACILITY DID NOT IMPLEMENT THE GOAL, ANSWER AS ( NI ) CODE FOR NOT IMPLEMENTING. IF DATA NOT AVAILABLE ANSWER AS ( ND ) CODE FOR NO DATA AND IF IT IS NOT APPLICABLE ANSWER AS ( NA ) CODE FOR NOT APPLICABLE.
Your answer
Goal 13 : Do you implement an Incident Report & Learning System? *
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