Professional Documents
Culture Documents
1. What?
3. How?
2. Why?
2
What ?
DEFINISI RISIKO
RISIKO ADALAH : POTENSI TERJADINYA KERUGIAN
YANG DAPAT TIMBUL DARI PROSES KEGIATAN SAAT SEKARANG ATAU KEJADIAN DIMASA DATANG. DATANG.
KATEGORI RISIKO DI RUMAH SAKIT : ( Categories of Risk ) Patient care-related risks careMedical staff-related risks staffEmployeeEmployee-related risks PropertyProperty-related risks Financial risks Other risks
Risiko yang berhubungan dengan perawatan pasien (Patient care related risks) risks)
Direct association with patient care Consequences of inappropriate or incorrectly performed medical treatments Confidentiality and appropriate release of information Protection from abuse, neglect and assault abuse, Was patient informed of risks? risks? Nondiscriminatory treatment Appropriate triage and transfer of patients from ER Patient participation in research studies and use of experimental drugs - was consent obtained? Was patient discharged appropriately?
Risiko yang berhubungan dengan tenaga medis (Medical staff - related risks) risks)
- Credential terhadap staf medis ? - Tindakan medis sesuai kompetensi dan prosedur baku ?
Protect assets from losses due to fires, floods, etc fires, floods, Paper and/or electronic records - patient, business and financial - protected from damage or destruction Procedures for handling cash and safeguarding valuables Bonding and insurance to protect facility from losses
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WHY ?
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HOSPITAL
System made up of thousands of interinter-linked processes.. processes.. things can go wrong
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HOW ?
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DIDALAM SISTEM KITA YANG SANGAT KOMPEKS INI .. BAGAIMANA KITA AKAN MENDARAT DENGAN SELAMAT ? BAHAYA / HAZARD / RISIKO YANG MANA YANG HARUS KITA TANGANI TERLEBIH DAHULU ?
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TEGAKKAN KONTEKS
IDENTIFIKASI RISIKO
RISK FINANCING :
- RISK RETENTION - RISK TRANSFER
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Risiko SELALU MELEKAT dengan proses pengobatan kepada pasien itu sendiri
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pengobatan dan perawatan kepada pasien; menentukan prioritas pelayanan ; pengembangan proyek dan pelayanan ; pembelian obat dan produk kesehatan lain; instruksi dan follow up kepada pasien.
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PROVIDING CARE IN THE EMERGENCY ROOM MAKING A DIAGNOSIS ORDERING INVESTIGATIONS AND INTERPRETING THE RESULTS UNDERTAKING INVASIVE PROCEDURES DRUG TREATMENT WARD MANAGEMENT
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RISK MANAGEMENT IN ER
POTENTIAL ERRORS Assessment of emergencies by insufficiently experienced junior staff Inadequate use of specialist opinion Inadequate reading of simple radiographs Poor management of standard situation Inadequate assessment before discharge REDUCING/MINIMISING RISKS Experienced clinicians available fullfull-time Involvement of specialist in the training of staff Training of staff on call radiologist Use protocols with sensitivity Senior staff to take responsibility for discharges
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REDUCING DIAGNOSTIC ERROR POTENTIAL ERRORS Failure to take a well-focused wellcase history Failure to assess the evidence & make a DD Inappropriate use of tests
REDUCING/MINIMISING RISKS
Concentrate on key elements Better training Write down conclusions before making a plan
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Consider The risk : benefit ratio Discuss the procedure with the patient Carrying out the procedure including coping with potential difficulties Ensure that the equipment is in good working order and that back up equipment is available If the procedure is not going well obtain help / be prepared to give up Ensure that the operator has sufficient skill
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Consider The risk : benefit ratio Discuss the procedure with the patient Carrying out the procedure including coping with potential difficulties Ensure that the equipment is in good working order and that back up equipment is available If the procedure is not going well obtain help / be prepared to give up Ensure that the operator has sufficient skill
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COMMON SPECIFIC FACTORS ASSOCIATED WITH DRUG ADVERSE EVENTS FAILURE TO TAKE ACCOUNT OF DECLINING RENAL / HEPATIC FUNCTION FAILURE TO CHECK FOR POSSIBLE ALLERGIC RESPONSES USING THE WRONG DRUG NAME OR MEANS OF ADMINISTRATION MISCALCULATION OF DOSAGE
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Use spesialist staff clinician from appropriate unit, nurse spesialist, physiotherapist Briefing & de-briefing deSBAR
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Shift working
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The basic principles for safety and quality of care The basic principles for patient safety are the principles for quality of care: care: - to do the right thing for the right patient using the right method and at the right time, and time, - to communicate well with the patient and the rest of the clinical team
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Its easy gettin good players. The hard part is gettin them to play with each other
(Casey Stengel)
(Casey
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Quality in Healthcare
. begins with ensuring patient safety
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Key reasons
Patients are more at risk than non-patients nonMedical interventions are, by their nature, highhigh-risk procedures - small error margins Medicine remains an inexact, hands-on inexact, handsendeavour
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Patient safety is an important component of risk management, clinical governance, and management, governance, quality improvement. improvement.
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CONCLUSIONS
I.
Risk management is not primarily about avoiding or mitigating claims; rather, it is a tool for
II. Incident reporting is only one aspect of the identification of risk. Incident reporting is on the reactive side of risk management. More emphasis needs to be placed on
in the
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FINAL WORD
Safe care is not an option. It is the right of every patient who entrusts their care to our Healthcare systems
Sir Liam Donaldson, Chair, WHO World Alliance for Patient Safety, Forward Programme, 20062007
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TERIMAKASIH
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