1.3.4
Safety and performance improvement activitiesIncident Reporting and Significant Incident (SIQ) Investigation
A structured process is in place for reporting, investigating and resolving adverse clinical events, sentinel events and significant incidents with corrective action.
Compliance Criteria
- 1Policy on incident reporting, mandatory notification timelines and no-blame culture
- 2Multidisciplinary Significant Incident / RCA committee convened for sentinel events
- 3SMART corrective action plans formulated and monitored until sustained closure
- 4Feedback loop to reporting clinical staff and hospital-wide learning dissemination
Hospital Self-Rating
Rated by Pn. Rohani binti Ismail on 22 Jan 2026Evidence frozen on 30 March 2026 (14 days before survey)
"Incident reporting is supported by an online portal. All sentinel and significant clinical incidents trigger a multidisciplinary RCA with corrective action implementation."
unsupported
No evidence documents attached to substantiate this self-assessment claim.
Unverified criteria:
- Policy on incident reporting, mandatory notification timelines and no-blame culture
- Multidisciplinary Significant Incident / RCA committee convened for sentinel events
- SMART corrective action plans formulated and monitored until sustained closure
- Feedback loop to reporting clinical staff and hospital-wide learning dissemination
Derived from AccrediSense Evidence Engine · 0 documents attached against 4 compliance criteriaGovernance disclosure (1.4.1.4)
Evidence Documents (0)
A criterion with no document reads as unevidenced to the survey team.
Attach relevant hospital policies, registers, audit reports, or training records.
RI
Person-in-ChargeQuality Manager
Head of DepartmentHead of Clinical Services & Consultant Physician
AR
Surveyor Authority Pane