Professional Documents
Culture Documents
anwar wardy
fkk umj
anwar wardy
fkk umj
Preventable
anwar wardy
Unpreventable
fkk umj
fkk umj
fkk umj
Patient death
Paralysis
Coma
4
5
anwar wardy
fkk umj
Error of
of
Error
Omission:
Omission:
Mislabeling aa test
test
Mislabeling
specimen
specimen
Drawing aa blood
blood
Drawing
sample from
from the
the
sample
wrong patient
patient
wrong
Incubating aa test
test at
at
Incubating
an incorrect
incorrect
an
temperature
temperature
anwar wardy
Omitting aa reagent
reagent
Omitting
in aa test
test
in
Failing to
to
Failing
communicate aa
communicate
critical test
test result
result
critical
Forgetting to
to
Forgetting
collect aa test
test sample
sample
collect
ataa specific
specific time
time
at
fkk umj
anwar wardy
fkk umj
(AHRQ Publication No. 04-RG005, December 2003. )-Agency for Healthcare Research and Quality-
1. Masalah komunikasi
a. Kegagalan komunikasi: verbal /
tertulis, miskomunikasi antar staf,
antar shift
b. Informasi tidak didokumentasikan
dgn baik / hilang
c. Masalah2 komunikasi : tim layanan
kesehatan di satu lokasi, antar
berbagai lokasi, antar tim layanan
dgn pekerja non klinis, & antar staf
dengan pasien
anwar wardy
a.
b.
c.
d.
fkk umj
(AHRQ Publication No. 04-RG005, December 2003. )-Agency for Healthcare Research and Quality-
anwar wardy
a.
b.
c.
d.
fkk umj
(AHRQ Publication No. 04-RG005, December 2003. )-Agency for Healthcare Research and Quality-
anwar wardy
fkk umj
(AHRQ Publication No. 04-RG005, December 2003. )-Agency for Healthcare Research and Quality-
fkk umj
8.
a.
b.
RS: Structure
Quality
Quality
Process of care
: AE
Costly
Cost: Invesment
Safety culture
-Culture
-Reporting
-Learning/Analysis/Research
-K&R-based Standard-Guideline
-Implementasi,Monitor
-Patient Involvement
Kepercayaan meningkat
Tema
: Membangun
Kepercayaan
anwar
wardy
Masyarakat kepada Rumah Sakit
Outcome
fkk umj
Blaming culture
-Pengaduan, Tuntutan
-Tuduhan Malpraktek(Pid/Perd)
-Proses Hukum:Polisi,Pengadilan
-Blow-up Mass Media, 90%
Publikasi-opini negatif
-Pertahanan RS :
-Pengacara
-RS/Dr : Asuransi
-Tuntutan balik
- Dsb
Kecurigaan meningkat
Involvement/
Communication
Pelaporan
Insiden
Implementasi &
Measurement
Pelatihan
Seminar
Pelayanan RS
yang lebih
aman
Analisis/Belajar
Riset
Pengembangan
Solusi
Panduan
Pedoman
Standar
anwar wardy
fkk umj
@PERSI, 2006
involvement
fkk umj
anwar wardy
fkk umj
Learning
cultures
Just
cultures
anwar wardy
fkk umj
anwar wardy
fkk umj
fkk umj
Atasan
langsung
Grading
Hijau/B
iru
Merah/
Kuning
Insiden
Investigasi
Sederhana
RCA
Sentinel
Rekomend
asi
anwar wardy
fkk umj
Tim
KP RS
Rekomendasi/P
embelajaran
Feedback ke
Unit Kerja
Sentinel
Komite
Medik
Masyarakat
KEH
Tim Penanganan
Kasus
anwar wardy
fkk umj
Lawyer Asuransi
anwar wardy
fkk umj