Professional Documents
Culture Documents
Santoso Soeroso
HEALTH TECHNOLOGY ASSESMENT PERSI
IMRS PERSI
Jakarta
BIODATA
Riwayat Pekerjaan :
Wakil Dir. Medik & Keperawatan RS Dr.
Kariadi , Semarang (1990-1995)
Wakil Dir. Umum & Keuangan RS Dr.
Kariadi, Semarang (1995-1998)
Dr.Santoso Soeroso SpA(K), MARS
Direktur RS Fatmawati (1998-2002)
Tempat & Tanggal lahir : Magelang, 22
Direktur RSPI-Sulianti Saroso (2002-
September 1947
2007)
Alamat kantor : Komite Medik RS Pondok
Chief Operating Officer RS Puri Indah
Indah, Jl. Metro Duta Kav UE, Jakarta
(Pondok Indah Group)
Selatan
Ketua II Health Technology Asseessment
Pendidikan :
Indonesia (2003-2013)
Dokter (FK UNDIP 1973) Dokter Spesialis
Ketua Bidang Kredensial Komite Medik
Anak (FK UNDIP 1982), Research Fellow
RS Pondok Indah
Pediatrc Cardiology, University of Lund,
Sweden 1984-1985, Reseach Fellow Anggota Institut Manajemen Rumah
Pediatric Cardiology , Tokyo Women Sakit – PERSI
Medical College, Japan, 1991-1992, SpA Ketua Divisi Health Technology
Konsultan 1992 Assessment - PERSI (2009-sekaramg)
MARS (FKM UI , 1996) Sekretaris, Badan Pertimbangan
Lemhannas KRA XXXIII (2000) Pemgurus Pusat IDAI (2012 – 2015)
The Institute of Medicine in 1999 issued a
report called “To Err is Human” that stated
that as many as 98,000 people die annually as
a result of medical errors.
Medical errors seriously harm one in every
10 patients around the world.
Patient Outcomes
PROCESSES:
Person * care process
* other processes
Individual &
Organizational
Tasks Outcomes
Environment
“The majority of safety problems in patient care are explained by a failure in communication and information management”
Situational Latent Active Failure
Factors Failure (Human Factors)
SAFETY BARRIERS
• Humans are “set up” to make errors that they are not responsible for
• Most errors result from faulty systems rather than human error
DEFENCES
Procedures
Physical barriers
Information
THE GAPS
Decisions
Poor protocols
Faulty equipment
Missing information
Patient
Inadequate supervision
harmed
Adapted from Professor James Reason
SEMBILAN SOLUSI LIFE-SAVING KESELAMATAN PASIEN RUMAH SAKIT
9 SOLUSI
1. Perhatikan Nama Obat, Rupa dan Ucapan Mirip (Look-Alike, Sound-Alike
Medication Names)
2. Pastikan Identifikasi Pasien
3. Komunikasi secara Benar saat Serah Terima/Pengoperan Pasien
4. Pastikan Tindakan yang benar pada Sisi Tubuh yang benar
5. Kendalikan Cairan Elektrolit Pekat (concentrated)
6. Pastikan Akurasi Pemberian Obat pada Pengalihan Pelayanan
7. Hindari Salah Kateter dan Salah Sambung Slang (Tube)
8. Gunakan Alat Injeksi Sekali Pakai
9. Tingkatkan Kebersihan Tangan (Hand hygiene) untuk Pencegahan Infeksi
Nosokomial.
Confusing drug names is one of the most common causes of
medication errors and is a worldwide concern. With tens of
thousands of drugs currently on the market, the potential for
error created by confusing brand or generic drug names and
packaging is significant. The recommendations focus on using
protocols to reduce risks and ensuring prescription legibility or the
use of preprinted orders or electronic prescribing.
The widespread and continuing failures to correctly identify
patients often leads to medication, transfusion and testing errors;
wrong person procedures; and the discharge of infants to the
wrong families. The recommendations place emphasis on methods for
verifying patient identity, including patient involvement in this process;
standardization of identification methods across hospitals in a health
care system; and patient participation in this confirmation; and use of
protocols for distinguishing the identity of patients with the same name.
1. Perhatikan Nama Obat, Rupa dan Ucapan Mirip (Look-Alike, Sound-Alike Medication
Names).
- NORUM membingungkan staf, adalah salah 1 sebab paling sering
kesalahan obat
- Solusi NORUM ditekankan pada penggunaan protokol untuk kurangi
risiko & pastikan terbacanya resep, label, atau penggunaan perintah yg
dicetak lebih dulu, maupun pembuatan resep secara elektronik.
Proses Analisis
(Unpreventable) (Preventable)
KTD Tidak dpt dicegah KTD / KNC Dpt dicegah
Forseeable - unavoidable, Medical Error, Medical
Acceptable, Unforseeable – Negligence,dsb
risk, dsb
Faktor Kontribusi
Penyebab IKP
Misdiagnosis
Penghentian
asuhan yang tidak
patut/abandonment
Contoh
Incident Report Form
Incident Report
Form ini digunakan untuk semua insiden (klinis dan non klinis). Jika lebih dari satu
orang terlibat dalam insiden yang sama, form yang terpisah harus dibuat untuk masing-
masing individu. Segera selamatkan korban, amankan lokasi, dan lakukan pertolongan
jika diperlukan; serta lakukan pencegahan agar tidak terjadi cedera pada yang lainnya.
Segera lengkapi form ini dan harus sudah diserahkan kepada Risk Management Officer
selambat-lambatnya dalam waktu 48 jam setelah insiden terjadi.
Hari / Tanggal Kejadian : Jam : (Gunakan sistem penulisan waktu 24 jam)
Lokasi kejadian : Gedung/Area/Lantai: Ruang (Tulislah sedetail mungkin):
Nama korban (Tulislah selengkap mungkin) : Pasien Pengunjung Petugas Lain-lain
Alamat Korban (Diisi jika korban bukan pasien):
Kerusakan Properti :MedisNon MedisNama Properti: Jenis
Kerusakan: Identitas Properti (Tulislah sedetail mungkin):
Nama saksi (Orang pertama yang mengetahui kejadian): Pasien Pengunjung
Petugas Lain-lain
Deskripsi singkat apa yang terjadi (Mohon dicatat juga dalam rekam medik. bila
diperlukan / Ingat! Hanya informasi yang objektif atau fakta ):
Safety Assessment Codes (SAC)
Matrix Looks
Severity Categories
Frequent (several 2 2 3 3
times in 1 year)
Occasional 1 2 3 3
(several times in 1 – 2
years)
Uncommon 1 1 2 3
(sometime in 2 – 5 years)
Remote (sometime 1 1 2 2
in 5 – 30 years)
Probability Categories
Frequent – Likely to occur immediately or within a short
period (may happen several times in 1 year).
Visitors: A death; or hospitalization of 3 or more visitors Equipment or facility: Damage equal to or more than
Staff : A death or hospitalization of 3 or more staff* $100,000** , ♦
Fire: Any fire that grows larger than an incipient stage‡
Moderate Minor
Patients with Actual or Potential: Increased length of stay or Patients with Actual or Potential: No injury, nor increased
increased level of care for 1 or 2 patients length of stay nor increased level of care
Visitors: Evaluation and treatment for 1 or 2 visitors (less than Visitors: Evaluated and no treatment required or refused
hospitalization) treatment
Staff : Medical expenses, lost time or restricted duty injuries or illness Staff: First aid treatment only with no lost time, nor restricted
for 1 or 2 staff duty injuries nor illnesses
Equipment or facility: Damage more than $10,000 but less than Equipment or facility: Damage less than $10,000 or loss of
$100,000** , ♦ any utilitywithout adverse patient outcome (e.g., power, natural
Fire – Incipient stage or smaller‡ gas, electricity, water, communications, transport, heat and/or
air conditioning)**, ♦
Angka Kejadian yang tidak diharapkankan menurut
hasil studi menggunakan data Rekam Medik
Retained instrument 1 0
Septicaemia
Spreading invasive
infection
Local infection/critical colo
nisation
Colonisation
Dg atau tanpa
Gejala klinis
Contamination
Lingkungan Rumah Sakit
Aseptik-1
Aseptik-0
Aseptik-2
Kamar Bedah (DaerahAseptik)
EQUIPMENT LIST
1 50,000 LUX МОВILЕ EMERGENCY LIGHT W/BACKUP ВАТТR.
2 TECHNICAL WALL FOR OPERATING ТНЕАТRЕ.
3 MUlTIPURPOSE MEDICAL ЕХАМ.& TREATMENT TROLLEY INCLUDING
RESUSCETATION UNIT FОR ADULT/СНILD/INFANT, ECG WITH PORTABLE
DEFIBRILLATOR AND MAJOR 5 РАВАМЕТЕRS MONITORING SУSТЕМ.
4 INFUSI0N STAND
5 SURGICAL SUTURES TROLLEY
6 KIDNEY DISH W/STAND.
7 КIСК BUCKET САRТ DN САSТОRS
8 UNIVRSAL OPERATING ТАВLЕ.
9 CEIlING SUSPENDED МАJOR OPERATING LIGHT.
10 SURGICAL INSTRUMENTS ТАВLЕ. GLАSS TOP.ON CASTORS
11 МАУО TROLLEY FOR OPERATING ТНЕАТRЕ
12 MONITORING SYSTEM-MODULAR РАRАМЕTЕRS- ON TROLLEY
13 LINEN НАМРЕR
14 SURGICAL INSTRUMENTS TROLLEY W/SНELVES AND DRAWERS.
15 SURGICAL DIATHERMY,CAUTERY ANO COAGULATION..
17 MOBILE UNNERSAL АNАЕSTНЕSIА UNIT W/VENTILATOR
18 2-JARS EMERGENCY SUCTION UNIT ON CASTORS
19 MOBILE UNIVERSAL ANAESTHESIA UNIT W/RESPERAT0R/VENTILATOR.
20 Х-RАУ FILM VIEWER (SINGLE, DOUBLE OR TRIPLE)
23 НОРРЕR
24 SURGEON STOOL W/CHESTREST
27 WORKING ВЕNСН W/LOWER CАBINETS & DRAWERS
32 STORING SHELVES AND РАCKS FOR MULTIPURPOSE STORAGE
33 SCRUB-UP.
34 DISINFECTANT LIQUID SOAP DISPENSER FOR HAND WASH
51 MULTI PURP0SE STORING CABINET
6O EMERGENCY DERBRILLATOR/РАСЕМАКЕ~ MOBIlE UNIT.
116 SERVICE PENDANT IN ОР.ТН. FOR POWER S0CKETS, MEDICAL GASES,
AND SCAVENGING SYSTEM OUTLET.
117 MOBIIE SURGICAL SUCTI0N UNIT ON CASTORS.
118 SURGICAL LASER UNIT ( CARBON DIOXIDE )
121 BACTERIACIDE LАМР
INFEKSI SALURAN NAFAS
HUMIDIFIER DAN NEBULIZER SBG SUMBER PENULARAN
HAI
CARA PENULARAN INFEKSI PADA PENGGUNAAN
VENTILATOR
ENDOGENOUS EXOGENOUS
ENDOGEN EXOGEN
Nebuliser
Nasal carrier Biofilm
BIOFILM
Sinusitis Ventilator-
Oropharynx circuit
Tracchea Health care-
Gastric workers
Patient Risks
•Clinical Risk Mgt
•Patient Safety
Hospital
Risk
Mgt
Property
Risks
Roberta Caroll, editor : Risk Management Handbook
for Health Care Organizations, 4th edition, Jossey
Bass, 2004
Scope of Hospital Risk Management (revised) :
of
The
Patient of
of The
The Hospital Health Care
Business Safety Worker
of of
The The
Environment Facilities
CLINICAL RISK MANAGEMENT