PRIVATE HEALTHCARE FACILlTIES AND SERVICES ACT

1998 [ACT 586]

&
PRIVATE HEALTHCARE FACILlTIES AND SERVICES
(PRIVATE HOSPITALS AND OTHER PRIVATE HEALTHCARE FACILlTIES)
REGULATIONS

2006

MANUAL ON
ASSESSABLE DEATH REPORTING

Private Medical Practice Control Section (CKAPS)

Medical Practice Division
Ministry of Health Malaysia

DECEMBER 2010

PAGE

CONTENTS

1.

Charter

2.

Goals of Reporting of Assessable Death

3.

Objectives of Reporting of Assessable Death

4.

Guiding Principles

5.

Methodology
5.1.

Interpretation of "Assessable" Death

5.2.

Notification and Data Collection of Assessable Death for Mortality

Review

5.3.

Retrieval of Patient Medical Record

5.4.

Confidentiality

5.5.

Fate of Notified Form AD-1

6.

Mortality Assessment Committee at Facility Level

7.

Access to the NMAC

Acknowledgement

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ASSESSABLE DEATH REPORTING

1.

Charter
A person in charge of a private healthcare facility ar service (PHFS) shall ensure
that every medical ar dentai practitioner who administers any anaesthesia ar
anaesthetic ar medical ar surgical procedure ar uses any medical technology on
any patient whose death that occurs within the PHFS, is an assessable death shall
notify the Director General the particulars of the assessable death as required
under subsection 67(1), Act 586.

2.

3.

Goals of Reporting of Assessable Death

2.1.

To provide information relating to the assessable deaths for National

Mortality Assessment Committee (NMAC) consideration.

2.2.

To determine the extent (if any) to which anaesthesia ar any anaesthetic

procedure, medical technology ar any medical procedure ar surgery ar any
surgical procedure contributed to the assessable death.

2.3.

To determine whether the assessable death might

the effects ar consequences of anaesthesia ar
medical technology ar any medical procedure ar
procedure, had been better ar more fully understood

2.4.

To improve the quality and standards of PHFS by promoting the safe and
efficient use of anaesthetic, medical ar surgical procedures, ar medical
technology based on NMAC's finding(s) and recommendation(s).

have been averted had

anaesthetic procedure,
surgery ar any surgical
ar provided for.

Objectives of Reporting of Assessable Death

3.1.

To collate data on "assessable" mortality in PHFS.

3.2.

To systematically assess the quality of anaesthetic, medical (including

medical technology) and surgical (including dentai) services and the quality
of supporting services and logistics by systematically reviewing the
information relating to assessable deaths which is aimed at identifying
shortfaIIs in such services hence taking remedial measures to prevent the
future occurrence of similar deaths.

3.3.

To look into relevant aspects of anaesthetic, medical and surgical care.

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4.

3.4.

To identify shortfaIIs in the delivery of the anaesthetic, medical and surgical

services.

3.5.

To recommend remedial measures in order to promote and attain the safe

and efficient use of anaesthetic, medical or surgical (including dentai)
procedures, or medical technology.

3.6.

To provide feedback on the results of the investigations to the relevant

private healthcare facility or service as well as the registered medical
practitioner.

Guiding Principles
In fulfilling its functions, the reporting of assessable death is bound by the folIowing
statutory guiding principles:
4.1.

Secrecy and Confidentiality (section 70)

4.1.1. Confidentiality of all information is assured and strictly adhered to,
except for the folIowing purposes:
(a)

Purposes connected with the functions of NMAC;

(b)

Purpose of an investigation of any alleged crime; or

(c)

Purpose of any criminal proceeding,

where all identification data from the reports are expunged before
being coded and reviewed by the members or "assessors" of the
NMAC who thus have no knowledge of the origin of the cases.
4.1.2. No person shall be compelled or permitted to divulge, in any civil
proceeding, any information relating to assessable death and no such
information shall be admissible as evidence in any civil proceedings.
4.2.

Non-punitive (subsection 66(3))

The inquiry looks at system problems
apportion blame to any individual.

4.3.

and deficiencies

and does not

Objectivity
Each case is independently assessed by members or "assessors" of the
NMAC who are specially chosen and who are in no way connected with the

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institution or persons in question

recommendation.

5.

before making any conclusion

and/ar

Methodology
This is a retrospective study of assessable death s in the PHFS.
5.1.

Interpretation
"Assessable death", under section 64 of the Private Healthcare Facilities and
Services Act 1998 refers to death that, in the opinion of any medical
practitioner or dentai practitioner, may be related to anaesthesia or any
anaesthetic procedure, or medical technology or any medical procedure, or
surgery or any surgical procedure.

5.2.

Notification and Data Collection of Assessable Death for Mortality Review

5.2.1. It is the duty of the person in charge of the private healthcare facility
or service to ensure that the relevant medical or dentai practitioner(s)
notify the Director General of Health, Malaysia (Secretariat) in writing
and preferably via electronic means of that death with in 72 hours
after he learns the occurrence of the death (subsection 67(1)) using
Form AD-1.
5.2.2. All assessable death patients' medical records are retained in the
private healthcare facility or service and marked "CONFIDENTIAL".
Completed notification forms (AD-1) will be sent to the NMAC
Secretariat at the Ministry of Health.
5.2.3. In addition, the medical or dentai practitioner(s) or any other relevant
persons may be required to furnish all or any specified information in
their possession relating to the assessable death including c1inical or
medical records or any other material or documents that are within
their control and may be required to assist the NMAC Working
Committee in any possible way as delineated under subsections 68(1)
and (2), Act 586.
5.2.4. Form
AD-1
can
be
accessed
http://medicalprac.moh .gov .my

5.3.

and

downloadable

at

Retrieval of Patient Medical Record

The patient medical record shall be kept in a safe place after any assessable
death to enable medical or dentai practitioners to have access to them for
reporting.

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5.4.

Confidentiality
Information in the Form AD-1 shall be expunged of all identification data
(such as the name of the deceased person, the names of the relevant
medical or dentai practitioners involved and the name of the private
healthcare facility or service or place where the death occurred pursuant to
subsection 68(3), Act 586.

5.5.

Fate of Notified Form AD-1

All Form AD-1 which have been completed and notified shall be kept until
such a time as when analysis of data and the annual report have been
completed, after which they may be destroyed.

6.

Mortality Assessment Committee at Facility Level

A PHFS is encouraged to conduct its own investigation into any assessable death
by form ing an internal or in-house mortality assessment committee as provided
under subsections 72(1), (2) and (3), Act 586 and the findings of such investigation
may be used to improve services of the PHFS.

7.

Access to the NMAC

The Committee can be contacted through its Secretariat at the folIowing:
NMAC Secretariat
.Private Medical Practice Control Section
Medical Practice Division
Ministry of Health Malaysia
Level 3, Block E1, Complex E
Federal Government Administrative
Centre
62590 PUTRAJAYA
Tel. No.: 03 - 88831296/1270
Fax No.: 03 - 8881 0901/0902
Email: irad@moh.gov.my
Website: http://medicalprac.moh.gov.my

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Acknowledgement

Medical Practice Division, Ministry of Health

Dr. Nooraini binti Baba

Dr. Ahmad Razid bin Salleh

Dr. Mohd Anis bin Haron @ Harun

Dr. Afidah binti Ali

Medical Development Division, Ministry of Health

Dr. PAA Mohamed Nazir bin Abdul Rahman

Association of Private Hospitais of Malaysia

Dr. T. Mahadevan
D

Puan Jasimah binti Hassan

Pharmaceutical Services Division

Puan Wan Mohaina binti Wan Mohammad

Puan Norleen binti Mohamed Ali

KPJ Healthcare Berhad

Pantai Holdings Berhad

Sunway Medical Centre

Gleneagles Medical Centre

Penang Adventist Hospital

National Heart Institute

Columbia Asia Sdn. Bhd.

Sime Darby Healthcare

Assunta Hospital

KPJ Selangor Specialist Hospital

Alpha Specialist Centre

Econ Medicare Centre

Lions Nursing Homes

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