e-IR 2.0 | MoH MALAYSIA HOSPITAL | REPORTING A PATIENT SAFETY INCIDENT
THIS FORM IS APPLICABLE FOR ALL HOSPITAL/HEALTH INSTITUTION IN MINISTRY OF HEALTH MALAYSIA

Fill in this form according to the IR form 2.0 received

Email address *
Fill in your Reference Number
Fill in a reference number for this report for future reference. This number is produced by your own facility.
Your answer
State / Negeri
Hospital Code *
Refer to the code provided.
Your answer
Date of Incident / Approximate date of incident *
Please enter according to this format ( DD/MM/YYYY ) . If approximate date , you can enter according to this format DD/MM/ YYYY or MM/YYYY or YYYY or UNKNOWN. D = Day , M = Month & Y = Year.
Your answer
Time of Incident / Approximate time of incident *
If the time of incident is unknown, enter as 00:00 AM.
Time
:
Patient Gender *
Age of Patient *
Please specify the patients' age
Type in the numbers only and select the unit for patients' age below. If the incident does not involve a specific person, kindly type in -1 for this question and select "years" for patients' age
Your answer
Unit for patients' age
Department(s) involved *
Required
Type of Patient *
Type of Patient Safety Incident *
Select Incident *
Describe the incident *
e.g wrong side below knee amputation, syrup Paracetamol 120mg was administered instead of 12mg, blood group A+ was wrongly transfused instead of O+, cardiac tamponade post chest tube insertion, retained tampon after SVD, patient fall at bedside resulting in right femur fracture, X-rays was taken at the wrong limb
Your answer
Patient Outcome *
Action Taken *
Required
Name of reporting officer *
Your answer
Designation reporting officer *
Your answer
Phone Number *
Your answer
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