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
Fill in your Reference Number
Fill in a reference number for this report for future reference. This number is produced by your own facility.
State / Negeri
W.P KUALA LUMPUR
Refer to the code provided.
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.
Time of Incident / Approximate time of incident
If the time of incident is unknown, enter as 00:00 AM.
Unknown / Others
Age of Patient
less than 1 month old
1 month - less than 1 year old
1 year and above
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
Unit for patients' age
Days of life
RADIOLOGY & IMAGING
Type of Patient
Type of Patient Safety Incident
Wrong surgery/procedure –wrong site, side or patient
Unintended retained foreign body in patient after an operation/procedure
Error in transfusion of blood / blood products
Medication error (please fill in MERS form as well)
Patient fall in the facility
Obstetric related incidents
Adverse outcome of clinical procedure
Pre-hospital care and ambulance service related incident
Radiotherapy related incident
Patient attempted suicide
Patient discharged to wrong family members / next-of -kin
Unanticipated Fire – Fire, flame, or unanticipated smoke, heat, or flashes occurring in the facility
Communication Related Issues
Radiology Related Incident
Assault / battery of patient
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
None/ No harm
Currently cannot be determined
Monitor The Trend First
Multi-incident Root Cause Analysis
Root Cause Analysis
Name of reporting officer
Designation reporting officer
Send me a copy of my responses.
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