Seminar Nasional VII PERSI 20 23 Agustus 2005

SUATU TANTANGAN BAGI PELAYANAN RUMAH SAKIT

Komite Keselamatan Pasien Rumah Sakit KKP-RS
PERSI Dr. Nico A. Lumenta, K.Nefro, MM

Pendahuluan Glossary Dasar : Mengapa Patient Safety Perkembangan Patient Safety di dunia Contoh Produk : Program, National Goals, Standar, Pedoman / Panduan, Pelaporan Kesimpulan Komite Keselamatan Pasien Rumah Sakit Kesimpulan

 Patient Safety adalah isu terkini, besar, penting, dalam Pelayanan Rumah Sakit, praktis belum lama, dimulai sejak th 2000an Menteri Kesehatan mencanangkan Gerakan Moral Keselamatan Pasien pada Seminar Nasional VII PERSI 21 Agustus 2005 Dalam jangka panjang tepat utk kondisi di Indonesia dgn maraknya tuduhan Malpraktek ( bias?) RS perlu melaksanakan Image Building meningkatkan kepercayaan masyarakat Telah dibentuk KOMITE KESELAMATAN PASIEN RUMAH SAKIT (KKP-RS) PERSI, pd tgl 1 Juni 2005 : Dalam tahap membangun Awareness RS, Unit Yan Kes, Org. Profesi, akan Keselamatan Pasien KP sdh dipresentasi ke Menteri Kesehatan, DirJen Bina YanMed, KaDinasKes DKI Jkt, dipaparkan pd pertemuan nasional : Raker MAKERSI Juli di Semarang, di Rakernas PELKESI Agustus di Tomohon Keselamatan Pasien selain masih dalam kerangka Peningkatan Mutu, juga merupakan pendekatan Green Product oleh Rumah Sakit ke masyarakat

Beberapa ciri penting RS

Rumah Sakit
1) Padat Modal 2) Padat Teknologi 3) Padat Karya 4) Padat Profesi *!* 5) Padat Sistem 6) Padat Mutu 7) Padat Risiko 8) Padat Keluhan/Masalah 9) Padat Error ? 10) RS = Kompleks yg padat

 Produk Barang - Jasa

Produk Barang
Pabrik Proses Produksi Bahan Produk Barang

Distribusi

Toko/Mal Transaksi

Rumah Konsumsi

Produk Jasa / Yan RS

Proses Produksi Produk Jasa (Distribusi) Transaksi Konsumsi

K
Konsumen :

- Kehadiran AZ - Keterlibatan tinggi : pasien = materi produk - Mengalami 3 elemen pokok

Isu makro rumah sakit :

(3)

SAFETY
Safety hadir sendiri/explisit, tetap terkait dgn Mutu

MUTU

ETIK

EBM

Safety is a fundamental principle of patient care and a critical component of quality management. (World Alliance for Patient Safety, Forward Programme, WHO, 2004)

Patient safety The prevention of harm caused by errors of commission and omission. (IOM) Patient safety The process by which an organisation makes patient care safer. This should involve: risk assessment; the identification and management of patient-related risks; the reporting and analysis of incidents; and the capacity to learn from and follow-up on incidents and implement solutions to minimise the risk of them recurring. (NHSNPSA) Patient safety incident Any unintended or unexpected incident which could have or did lead to harm for one or more patients. (NHS-NPSA)

Medical errors Mistakes made in the process of care that result in or have the potential to result in harm to patients. Mistakes include the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Can be the result of an action that is taken (error of commission) or an action that is not taken (error of omission).
Medical error An adverse event or near miss that is preventable with the current state of medical knowledge. (QuIC)

Adverse event An event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient. (IOM) Adverse event An injury that was caused by medical management and that results in measurable disability. (QuIC) Adverse event An injury that was caused by medical management (rather than underlying disease) and that prolonged the hospitalization produced a disability at the time of discharge, or both. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. New England Journal of Medicine 1991; 324:370-376. Unpreventable adverse event An adverse event resulting from a complication that cannot be prevented given the current state of knowledge. (QuIC)

Near miss An error of commission or omission that could have harmed the patient, but serious harm did not occur as a result of chance (e.g., the patient received a contraindicated drug but did not experience an adverse drug reaction), prevention (e.g., a potentially lethal overdose was prescribed, but a nurse identified the error before administering the medication), or mitigation (e.g., a lethal drug overdose was administered but discovered early and countered with an antidote). (IOM) Near miss An event or situation that could have resulted in an accident, injury or illness, but did not, either by chance or through timely intervention. Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. Report of the Quality Interagency Coordination Task Force to the President, Feb 2000. Quality Interagency Coordination Task Force. Washington, D.C.

Incident reporting A process used to document occurrences that are not consistent with routine hospital operation or patient care. Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995; 21(10):541-548.

Risk management In the context of hospital operations, the term risk management usually refers to self-protective activities meant to prevent real or potential threats of financial loss due to accident, injury, or medical malpractice. Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999; 131(12):963-967.

Pasien tidak cidera

Near Miss

(NM)

Medical Error
-Kesalahan proses -Dpt dicegah -Pelaks Plan action Pasien tdk komplit cidera -Pakai Plan action yg salah -Krn berbuat : commission -Krn tidak berbuat : omission

-Dpt obat c.i., tdk timbul (chance) -Plan, diket, dibatalkan (prevention) -Dpt obat c.i., diket, beri anti-nya (mitigation)

Adverse Event

(AE)

(KTD=Kejadian Tdk Diharapkan)

Proses of Care
(Non Error)

Pasien cidera

Adverse Event

Figure 1: Venn diagram representing Institute of Medicine terminology

All episodes of care All Errors

All Adverse Events
(Near Miss) Preventable Adverse Events Negligent Adverse Events
(Adverse Events Non Error) (Unpreventable AE)

Gray,A :Adverse events and the National Health Service, an economic perspective, report to the National Patient Safety Agency , November 2003

Type of Errors
Diagnostic Error or delay in diagnosis Failure to employ indicated tests Use of outmoded tests or therapy Failure to act on results of monitoring or testing Treatment Error in the performance of an operation, procedure or test Error in administering the treatment Error in the close of method of using a drug Avoidable delay in treatment or in responding to an abnormal test Inappropriate (not indicated) care Preventive Failure to provide prophylactic treatment Inadequate monitoring or follow up of treatment Other Failure of communication Equipment failure Other system failure
Leape, Lucian; Lawthers, Ann G.; Brennan, Troyen A., et al. Preventing Medical Injury. Qual Rev Bull. 19(5):144149, 1993.

 First, do no harm : Hippocrates (460-335 BC). Pelayanan Kesehatan pada dasarnya adalah untuk menyelamatkan pasien Rumah Sakit :
Quality Quality Quality

Structure

Process of care

Outcome

Sejak awal 1900 institusi RS selalu meningkatkan MUTU pada ke-3 elemen tsb diatas : Standar Pelayanan, Penerapan QA, TQM, CQI, Perizinan, Credentialing, Akreditasi, ISO, Baldridge Award, Performance measurement, Benchmarking, Hospital/Clinical Governance, Clinical Indicator, EBM/P, Etik Profesi / RS, Risk Management. . .

Namun : . . . . .

Quality

Quality

Quality

RS: Structure

Process of care

Outcome

Near Miss : Everyday, tens if not hundred

thousands of error occur in the US health care system .these errors not in serious harm but in Near Miss
(Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety: achieving a new standard for care. Washington, D.C.: National Academy Press, 2004.)

Adverse Event : 3.2 16.6 %

!!!
(WHO, 2004)

Sektor Yan Kesehatan selama ini tidak rutin mendata informasi tentang error
(Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety: achieving a new standard for care. Washington, D.C.: National Academy Press, 2004.)

Masih ada 3 isu lain disamping error :

How good is the quality of care ?

E.A. McGlynn, 1998 (Presidents Advisory Commission on Consumer Protection and Quality in Health Care Industry)
Overuse : *CABG 14% procedure inappropriate : Inggris 21 %, Canada 9%. * URTI : 30-70% inappropriate prescriptions of antibiotics for viral infection. *NSAIDS : 42% unnecessary prescription Under use : *76 % anak : immunisasi lengkap. * Pasien DM hanya 16% diperiksa HbA1C. * Pasien dengan CAD perlu intervensi : hanya dilaksanakan 42 % (Black) & 61% (White) yang CABG / PTCA Variasi pelaksanaan YanKes : *Daerah North east : West lebih tinggi : prostatectomy 13%,cholecystectomy 48%, cardiac catheterization 30%, CABG 30%, CT Scan 159%. *South : West : lebih tinggi Hysterectomy 50%. *South : North east : lebih tinggi Appendictomy 32%, S.C. 37% *Midwest : West : lebih tinggi Mastectomy 86% Error : *Medication error 4 per 1000 : terbanyak pd antibiotik, obat cardio-vaskuler, obat gastrointestinal & narkotik. *14% kematian pada stroke, pneumonia dan serangan jantung apat dicegah (12 RS)

IOM (Institute of Medicine) : TO ERR IS HUMAN

IOM, 1998 : Committee on quality of Health Care in America membuat laporan :

TO ERR IS HUMAN,
Building a Safer Health System (2000)
1) Adverse Event bukan baru, namun laporan berhasil mengangkat fokus perhatian : - AE di RS di Colorado & Utah : 2,9 % pasien RS, yang meninggal 6,6 % - Di New York : 3,7 %, yang meninggal 13,6 % - Pasien admisi di RS pada th tsb (1997) 33,6 juta - Extrapolasi : Pasien mati karena Medical Error : 44.000 98.000.
(Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, D.C.: National Academy Press, 2000.)

Laporan IOM: TO ERR IS HUMAN, building a safer health system.

RS

AE
(>50% krn ME)

Mati

US
RS:Adm /year

US
RS:Mati sb AE/ME
Extrapolasi

Mati sb lain

Di Colorado Utah(1992) Di New York(1984)

2.9 %

6.6 %
33.6 juta 44,000 98,000 !!!

3.7 %

13.6 %

- KLL : 43,458 -Cancer : 42,297 -AIDS : 16,516

(Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, D.C.: National Academy Press, 2000.)

Laporan To Err is Human fokus pd ME di RS krn data tersedia. Tetapi di sarana yan kes lain (ambulatory setting & nursing homes) jumlah kunjungan sangat besar ME juga serius, shg ME di RS tampak sangat kerdil. (Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety:achieving a new standard for care. Washington, D.C.: National Academy Press, 2004.)

2) Laporan IOM menyimpulkan 4 hal pokok : A. Masalah accidental injury adalah serius B. Penyebabnya bukan kecerobohan individu, tetapi kesalahan sistem C. Perlu redesign sistem pelayanan D. Patient Safety harus menjadi prioritas nasional 3) IOM mengajak (challenge) semua pihak melibatkan diri
(Leape L et al, Editorials, New England J. of Medicine 2002, 347 : 1272-1273)

4) Segera Congress mengadakan dengar pendapat. Pres.Clinton membentuk : Quality Interagency Coordination Task Force (QuIC) menganalisa laporan IOM tsb
The message of the report has resonated ever since, from the halls of Congress to the hallways of health care facilities across the nation. : Mary K. Wakefield, AHRQ Publication No. 05-0021-4 (Vol. 4), February 2005

(WHO : World Alliance for Patient Safety, Forward Programme, 2004)

Di INDONESIA

KEKERAPAN TUNTUTAN
DI INGGRIS
TIAP HARI TERJADI KELALAIAN MEDIS

DI AUSTRALIA
KLAIM DITUJUKAN PADA 11,8 / 1000 PESERTA ASURANSI PROFESI

DI SINGAPURA
KLAIM DITUJUKAN PADA 10,7 / 1000 PESERTA ASURANSI PROFESI

DI JAKARTA
PIDANA: 48 KASUS DI POLDA METRO PERDATA: 160 KASUS DIAJUKAN LBH KESEHATAN
*KaDinKes DKI Jkt (8Juli2005): setiap minggu ada 2 3 pengaduan pasien
(Budi Sampurna, Seminar Perumahsakitan, Surabaya, 24 Maret 2005)

KEKERAPAN ERRORS DI RUMKIT

DI A.S.:
KESALAHAN PEMBERIAN OBAT DI 2 RUMKIT DI AS: 56% DAN 34% (BATES, 1995) KESALAHAN BEDAH : 1:50 PASIEN RAWAT (GAWANDE, 1999)

DI INDONESIA:
Iwan Dwiprahasto MMedSc, PhD di Jogja: MEDICATION ERROR DI I.C.U. MENCAPAI 96% (TAK SESUAI INDIKASI, TAK SESUAI DOSIS, POLIFARMAKA TAK LOGIS, DLL) MEDICATION ERROR DI PUSKESMAS: 80-AN %
(Budi Sampurna, Seminar Perumahsakitan, Surabaya, 24 Maret 2005)

Amerika
1. IOM (Institute of Medicine) : - To err is Human, Building a Safer Health System (2000) - Patient Safety, Achieving a new standard for care (2004) rekomendasikan 3 hal pokok : a. Infrastruktur Sistem Informasi Kesehatan Nasional diperlukan untuk membuat Standar Keselamatan Pasien b. Semua organisasi kesehatan perlu menetapkan Program Keselamatan Pasien yang komprehensif dijalankan oleh Staf yang terlatih c. Perlu standardisasi Pelaporan & Terminologi Keselamatan Pasien 2. AHRQ : Agency for Healthcare Research and Quality (www.ahrq.gov) - 2001 : Center for Quality Improvement and Patient Safety (CQuIPS) - 2003 : Guide to Patient Safety Indicators 3. Pres. Clinton : Quality Interagency Coordination Task Force menetapkan kebijakan nasional :

A. Mengangkat suatu Fokus Nasional utk membentuk Kepemimpinan, Riset, Instrumen, Pedoman meningkatkan pengetahuan tentang Keselamtan Pasien B. Melakukan identifikasi dan belajar dari medical errors melalui Sistem Laporan yg wajib maupun sukarela C. Meningkatkan / memperbaiki standar Keselamtan Pasien D. Implementasikan kegiatan keselamatan pasien di ujung tombak pelayanan 4. JCAHO (Joint Comm. On Accreditation for Healthcare organization) - Setiap tahun menetapkan National Patient Safety Goals(sejak 2002) - Juli 2003 : Pedoman The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery - Maret 2005 mendirikan International Center for Patient Safety 5. NPSF : National Patient Safety Foundation. (AMA) - Perbaiki Keseamatan Pasien - Identifikasi & susun a core body of knowledge - Tingkatkan kesadaran publik ttg keselamtan pasien

Australia
1. Australian Council for Safety and Quality in Health Care : - Jan 2000 dibentuk oleh MOH Australia dgn dukungan Australian Health Ministers. (www.safetyandquality.org) - Fungsi : pimpin kegiatan nasional memperbaiki keselamatan dan mutu yan kesehatan, utamanya menekan error - Tujuan : 1) Kembangkan Standar & Pedoman, 2) Tingkatkan data & analisis AE 3) Berdayakan konsumen utk memperbaiki keselamatan pasien 4) Redisain sistem kesehatan, 5) Tingkatkan kesadaran masyarakat ttg keselamatan pasien
2. APSF : Australian Patient Safety Foundation Inc (July 1989) - Asalnya dari Program Incident Monitoring pada Anestesi

3. Australias First Patient Safety Research Centre (Dec 2004)

4. Program AIMS : - Australian Incident Monitoring System

Inggris
1. NPSA = National Patient Safety Agency, 2001 Juli : dibentuk pemerintah / NHS - Koordinasi kegiatan laporan, belajar dari kesalahan dan masalah keselamatan pasien - Pastikan kesalahan dilaporkan pd kesempatan pertama - Dorong staf kesehatan melapor insiden tanpa takut ditegur - Kumpulkan laporan dari seluruh daerah & prakarsai langkah pencegahan, shg secara nasional kasus2 dpt dipelajari, dan keselamatan pasien dpt diperbaiki improved. 2. National Reporting and Learning System (NRLS) - Laporan secara elektronik - Laporan bersifat anonim - Menerbitkan : : Seven steps to patient safety, An overview guide for NHS staff .

Canada
1. NSCPS : National Steering Committee on Patient Safety : 2. CPSI : Canadian Patient Safety Institute - dibentuk oleh Pemerintah Federal, 2003 - Agenda pokok badan2 ini : Bentuk budaya keselamatan pasie, tingkatkan mutu yan kesehatan - Rekomendasi a. Bangun kesadaran dan tentukan prioritas utk memperbaiki keselamatan pasien b. Kembangkan sistem pelaporan yg lebih baik c. Kembangkan ketrampilan, pengetahuan & implementasi sistem keselamtan pasien d. Bentuk organisasi & kebijakan yg mendukung kegiatan keselamatan pasien 3. AHSC (Academic Health Services Centre) : riset keselamatan pasien 4. ACAHO (Association of Canadian Academic Health care organizations) : strategy keselamatan pasien 5. ACEN (Academy of Canadian Executive Nurses) : strategy keselamatan pasien

Denmark
Denmark is one place from which practitioners may draw inspiration. In June 2003 it became the first country to adopt a national law on patient safety. The law states that hospital operators must receive, register, and analyse reports on adverse events. A nurse or doctor who becomes aware of such an incident or a near miss must report it. The details are logged in a national register. The reports do not include details that can identify people, and medical staff cannot be subjected to disciplinary action for reporting any incidents.

Malaysia

1. 2. 3. 4. 5.

Patient Safety Council : - September 2004, dibentuk oleh MOH - 5 fungsi : Kembangkan sistem database electronik utk pelaporan & dokumentasi medical errors di RS Promosikan sistem pelaporan insiden yg adil dan konfidensial Analisa insiden & belajar menghindari/mencegahnya Susun strategi memperbaiki keselamatan dan mutu Publikasi laporan ttg AE & keselamatan pasien

WHO
- Pada World Health Assembly ke 55 Mei 2002 ditetapkan suatu resolusi yang mendorong (urge) negara untuk memberikan perhatian kepada problem Patient Safety meningkatkan keselamatan dan sistem monitoring - Okt 2004 WHO dan berbagai lembaga mendirikan World Alliance for Patient Safety dgn tujuan mengangkat Patient Safety Goal First do no harm dan menurunkan morbiditas, cidera dan kematian yang diderita pasien (www.who.int/patientsafety)

WHO
World Alliance for Patient Safety Programme : six areas of action. (2005)
1. Global Patient Safety Challenge, focusing over an initial two-year cycle on the challenge of health-care associated infection;2005-2006: "Clean Care is Safer Care 2. Patients for Patient Safety Involving patient organisations and individuals in Alliance work; 3. Taxonomy for Patient Safety Ensuring consistency in the concepts, principles, norms and terminology used in patient safety work; 4. Research for Patient Safety promoting existing interventions in patient safety and coordinating international efforts to develop solutions; 5. Solutions for Patient Safety promoting existing interventions in patient safety and coordinating international efforts to develop solutions; and 6. Reporting and Learning Generating best practice guidelines for existing and new reporting systems.

WHO World Alliance for Patient Safety Programme : six areas of action. (2005)
SPEAK UP (Action 2) : Speak up if you have questions or concerns: it's your right to know Pay attention to the care you are receiving Educate yourself about your diagnosis, test and treatment Ask a trusted family member or friend to be your advocate Know what medications you take and why you take them Use a health-care provider that rigorously evaluates itself against safety standards Participate in all decisions about your care.

NHS-NPSA : Seven steps to patient safety,

An

overview guide for NHS staff. Second print April 2004 1 Build a safety culture : Create a culture that is open and fair 2 Lead and support your staff : Establish a clear and strong

focus on patient safety throughout your organisation 3 Integrate your risk management activity : Develop systems and processes to manage your risks and identify and assess things that could go wrong 4 Promote reporting : Ensure your staff can easily report incidents locally and nationally 5 Involve and communicate with patients and the public : Develop ways to communicate openly with and listen to patients 6 Learn and share safety lessons : Encourage staff to use root cause analysis to learn how and why incidents happen 7 Implement solutions to prevent harm : Embed lessons through changes to practice, processes or systems (www.npsa.nhs.uk/sevensteps)

(Seven steps to patient safety, An overview guide for NHS staff April 2004)

A major element of programmes to improve patient safety is having the capacity and capability to capture comprehensive information on adverse events, errors and near-misses so that it can be used as a source of learning and as the basis for preventive action in the future. (WHO : World Alliance for Patient Safety, Forward Programme, 2004 )

NHS-NPSA :

Seven steps to patient safety, An overview guide for NHS staff.

Step 1 Second print April 2004 Build a safety culture Action points For your organisation: ensure your policies state what staff should do following an incident, how it should be investigated, and what support should be given to patients, families and staff; ensure your policies describe individual roles and accountability for when things go wrong; assess your organisations reporting and learning culture using a safety assessment survey (see Resources from the NPSA on page 10). For your team: ensure your colleagues feel able to talk about their concerns and report when things go wrong; demonstrate to your team the measures your organisation takes to ensure reports are dealt with fairly and that the appropriate learning and action takes place.

Step 2 Lead and support your staff Action points For your organisation: ensure there is an executive board member with responsibility for patient safety; identify patient safety champions in each directorate, division or department; put patient safety high on the agenda of board or management team meetings; build patient safety into the training programmes for all your staff and ensure this training is accessible and measure its effectiveness. For your team: nominate your own champion or lead for patient safety; explain the relevance and importance of patient safety to your team, and the benefits it brings; promote an ethos where all individuals within your team are respected and feel able to challenge when they think something may be going wrong.

Step 3 Integrate your risk management activity Action points For your organisation: review your structures and processes for managing clinical and nonclinical risk, and ensure these are integrated with patient and staff safety, complaints and clinical negligence, and financial and environmental risk; develop performance indicators for your risk management system which can be monitored by your board; use the information generated by your incident reporting system and organisation-wide risk assessments to proactively improve patient care. For your team: set up local forums to discuss risk management and patient safety issues and provide feedback to the relevant management groups; assess the risk to individual patients in advance of treatment; have a regular process for assessing your risks, for defining the acceptability of each risk and its likelihood, and take appropriate actions to minimise them; ensure these risk assessments are fed into the organisation-wide risk assessment process and risk register.

Step 4 Promote reporting Action points For your organisation: complete a local implementation plan (see below) which describes how and when your organisation will begin reporting nationally to the NPSA. For your team: encourage your colleagues to actively report patient safety incidents that happen and those that have been prevented from happening but that carry important lessons.

Step 5 Involve and communicate with patients and the public Action points For your organisation: develop a local policy covering open communication about incidents with patients and their families; ensure patients and their families are informed when things have gone wrong and they have been harmed as a result; provide your staff with the support, training and encouragement they need to be open with patients and their families. For your team: ensure your team respects and supports the active involvement of patients and their families when something has gone wrong; prioritise the need to tell patients and their families when incidents occur, and to provide them with clear, accurate and timely information; make sure patients and their families receive an immediate apology where it is due, and are dealt with in a respectful and sympathetic way.

Step 6 Learn and share safety lessons Action points For your organisation: ensure relevant staff are trained to undertake appropriate incident investigations that will identify the underlying causes; develop a local policy which describes the criteria for when your organisation should undertake a Root Cause Analysis (RCA) or Significant Event Audit (SEA). These criteria should include all incidents that have lead to permanent harm or death. For your team: share lessons from the analysis of patient safety incidents within your team; identify which other departments might be affected in future, and share your learning more widely.

Step 7 Implement solutions to prevent harm Action points For your organisation: use the information generated from incident reporting systems, risk assessments, and incident investigation, audit and analysis to identify local solutions. This could include re-designing systems and processes, and adapting staff training or clinical practice; assess the risks for any changes you plan to make; measure the impact of your changes; draw on solutions developed externally. These could be solutions developed at a national level by the NPSA or best practice identified elsewhere in the NHS; provide staff with feedback on any actions taken as a result of reported incidents. For your team: involve your team in developing ways to make patient care better and safer; review changes made with your team to ensure they are sustained; ensure your team receives feedback on any follow-up to reported incidents.

AHRQ : 20 Tips To Help Prevent Medical Errors

(untuk Pasien / Masyarakat)
1.The single most important way you can help to prevent errors is to be an active member of your health care team. 2. Make sure that all of your doctors know about everything you are taking. This includes prescription and over-the-counter medicines, and dietary supplements such as vitamins and herbs. 3. Make sure your doctor knows about any allergies and adverse reactions you have had to medicines. 4. When your doctor writes you a prescription, make sure you can read it. 5. Ask for information about your medicines in terms you can understand both when your medicines are prescribed and when you receive them 6. When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed?
Patient involvement : ..in general, patients (and their family & friends) are a vastly underutilized resource for identifying things that go wrong in health care. (Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety: achieving a new standard for care. Washington, D.C.: National Academy Press, 2004.)

7. If you have any questions about the directions on your medicine labels, ask 8. Ask your pharmacist for the best device to measure your liquid medicine. Also, ask questions if youre not sure how to use it. 9. Ask for written information about the side effects your medicine could cause. 10. If you have a choice, choose a hospital at which many patients have the procedure or surgery you need. 11. If you are in a hospital, consider asking all health care workers who have direct contact with you whether they have washed their hands. 12. When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will use at home.

13. If you are having surgery, make sure that you, your doctor, and your surgeon all agree and are clear on exactly what will be done 14. Speak up if you have questions or concerns. 15. Make sure that someone, such as your personal doctor, is in charge of your care. 16. Make sure that all health professionals involved in your care have important health information about you. 17. Ask a family member or friend to be there with you and to be your advocate (someone who can help get things done and speak up for you if you cant). 18. Know that more is not always better. 19. If you have a test, dont assume that no news is good news. 20. Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources. (www.ahrq.gov/errors.htm.)

AHRQ : 30 Safe Practices for Better Health Care (untuk Staff)

1. Create a health care culture of safety. 2. Elective surgical procedures-patients should be clearly informed- treatment facilities superior outcomes -should be referred to such facilities in accordance with the patients stated preference. 3. Specify an explicit protocol to be used to ensure an adequate level of nursing 4. All patients in general intensive care units should be managed by physicians having specific training and certification in critical care medicine (critical care certified). 5. Pharmacists should actively participate in the medication-use process 6. Verbal orders should be recorded whenever possible and immediately read back to the prescriber; 7. Use only standardized abbreviations and dose designations.

8. Patient care summaries or other similar records should not be prepared from memory. 9. Care information, especially changes in orders and new diagnost information, is transmitted in a timely and clearly understandable form to all of the patients current health care providers who need that information to provide care 10. Ask each patient or legal surrogate to recount what he or she has been told during the informed consent discussion. 11. Ensure that written documentation of the patients preference for life-sustaining treatments is prominently displayed in his or her chart. 12. Implement a computerized prescriber-order entry system. 13. Implement a standardized protocol to prevent the mislabeling of radiographs. 14. Implement standardized protocols to prevent the occurrence of wrong-site or wrong-patient procedures.

25. Decontaminate hands with either a hygienic hand rub or by washing with a disinfectant soap prior to, and after, direct contact with the patient or objects immediately around the patient. 26. Vaccinate health care workers against influenza to protect both them and patients. 27. Keep workspaces where medications are prepared clean, orderly, well lit, and free of clutter, distraction, and noise. 28. Standardize the methods for labeling, packaging, and storing medications. 29. Identify all high alert drugs (for example, intravenous adrenergic agonists and antagonists, chemotherapy agents, anticoagulants and anti-thrombotics, concentrated parenteral electrolytes, general anesthetics, neuromuscular blockers, insulin and oral hypoglycemics, narcotics, and opiates). 30. Dispense medications in unit-dose or, when appropriate, unit-of-use form, whenever possible. (www.ahrq.gov/qual/nqfpract.htm.)

How to Prevent Medical Mistakes Medical Mistakes Can Happen A Patient Safety Message brought to you by
(Pasien/Masyarakat)

In the Hospital: Because there are hundreds of medications, tests and procedures, and many patients and clinical staff members in a hospital, it is quite easy for a mistake to be made. Such mistakes can include giving someone the wrong medication, performing the wrong tests (such as lab tests or Xrays), performing the wrong procedures, or neglecting to do any of the above when they have been ordered by a doctor.

Patient identification Whether your care giver is taking blood, giving you medication, or performing a test or procedure, you want to make sure that it is meant for you. It is OK to ask your caregiver for whom the test, procedure or medication is intended. Read Back Each time a new staff person comes to give you medication or treatment, greet them and tell them your name. Ask them to tell you their name and explain what the procedure is, who ordered it, and what to expect from it. Ask them to read back the order to you. If the information is different than what you expect, alert the staff member immediately, and request an explanation. Post your name on the wall above your bed.

Pelaporan
TABLE 2. CHARACTERISTICS OF SUCCESSFUL REPORTING SYSTEMS.* Characteristic Explanation Nonpunitive Reporters are free of fear of retaliation or punishment from others as a result of reporting. Confidential The identities of the patient, reporter, and institution are never revealed to a third party. Independent The program is independent of any authority with power to punish the reporter or organization. Expert analysis Reports are evaluated by experts who understand the clinical circumstances and who are trained to recognize underlying systems causes.
Reporting of Adverse Events: Leape, L.L., N Engl J Med, Vol. 347, 1633-1638, 2002

Timely

Reports are analyzed promptly, and recommendations are rapidly disseminated to those who need to know, especially when serious hazards are identified. Systems-oriented Recommendations focus on changes in systems, processes, or products, rather than on individual performance. Responsive The agency that receives reports is capable of disseminating recommendations, and participating organizations agree to implementing recommendations when possible. *Adapted from Cohen,22 Connell,30 Cohen,36 and Gaynes et al.37
Reporting of Adverse Events: Leape, L.L., N Engl J Med, Vol. 347, 1633-1638, 2002

TABLE 3. LIST OF SERIOUS REPORTABLE EVENTS.* Surgical events Surgery performed on the wrong body part Surgery performed on the wrong patient Wrong surgical procedure performed Retention of foreign object in a patient after surgery or another procedure Death of patient with an ASA class I risk during or immediately after surgery Events involving products or devices Death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the health care facility Death or serious disability associated with the use or function of a device that is other than the intended use or function Death or serious disability associated with intravascular air embolism that occurs while the patient is receiving care in a (Reporting of Adverse Events: Leape, L.L., N Engl J Med, health care facility Vol. 347, 1633-1638, 2002)

Events involving patient protection Infant discharged to the wrong person Death or serious disability associated with a patients disappearance for more than four hours Suicide, or attempted suicide resulting in serious disability, while patient is receiving care in a health care facility Events involving care Death or serious disability associated with a medication error (e.g., an error involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration) Death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood product Death or serious disability associated with labor or delivery in a low-risk woman receiving care in a health care facility Death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is receiving care in a health care facility

Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in a neonate Stage III or IV pressure ulcers acquired after admission to a health care facility Death or serious disability due to spinal manipulative therapy Environmental events Death or serious disability associated with an electric shock while patient is receiving care in a health care facility Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances Death or serious disability associated with a burn incurred while patient is receiving care in a health care facility Death associated with a fall while patient is receiving care in a health care facility Death or serious disability associated with the use of restraints or bedrails while patient is receiving care in a health care facility

Criminal events Any instance of care ordered or provided by someone impersonating a physician, nurse, pharmacist, or other health care provider Abduction of a patient of any age Sexual assault on a patient within or on the grounds of a health care facility Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) within or on the grounds of a health care facility *Modified from the National Quality Forum.25 ASA denotes American Society of Anesthesiology.

Reporting of Adverse Events: Leape, L.L., N Engl J Med, Vol. 347, 1633-1638, 2002

Mengapa Patient Safety

Quality Quality Quality

RS: Structure
Cost: Invsment

Process of care

Outcome
Costly

: AE

Patient Safety -Culture -Reporting -Learning/Analysis/Research -K&R-based Standard-Guideline -Implementasi,Monitor -Patient Involvement Kepercayaan meningkat

Blaming
-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

Manfaat RS terapkan Keselamatan Pasien

Kecenderungan Green Product -produk yang aman- di bidang industri lain, al.menjadi persyaratan dlm berbagai proses transaksi, sehingga menjadi makin laku/laris, makin dicari masyarakat RS yang menerapkan KP akan lebih dicari oleh 3rd Party Payer : Perusahaan-perusahaan dan Asuransi-asuransi akan mengutamakan memakai RS-RS tsb sebagai provider kesehatan karyawan / klien mereka, & kemudian akan diikuti oleh masyarakat yang akan lebih mencari RS yang aman. Kegiatan RS di kawasan Blaming akan menurun krn fokus di kawasan Patient Safety,

PATIENT SAFETY BLAMING

2005 2008 2010

Kesimpulan
1) Di berbagai negara yang notabene adalah negara maju, termasuk mutu pelayanan kesehatan dan teknologi kesehatannya, tenyata Medical Error yang berakibat Adverse Event (AE) tidak kecil jumlahnya. Apalagi Near Miss ada 10-100 ribuan tiap hari di US (Disamping : Overuse, Underuse, Variasi Pelayanan)

2) Di Indonesia data AE ini masih minim, tetapi diasumsikan tidak kalah besarnya
3) AE meningkatkan biaya, proses2 Blaming merugikan semua pihak, kecurigaan meningkat, semua pihak rugi : lose-lose outcome

4) Patient Safety / Keselamatan Pasien adalah solusi yang menguntungkan: win-win situation, kepercayaan meningkat. Di banyak negara sejak th2000an Patient Safety sudah diangkat menjadi fokus nasional, partisipasi luas berbagai organisasi 5) Elemen pokok Sistem Keselamatan Pasien, yang bertujuan menekan kejadian AE, terdiri dari :

I. II. III. IV.

Reporting Analyzing /Learning, Research, Taxonomy Solution development Knowledge & Research based StandardsPractices-Guidelines for Patient Safety V. Patient involvement-empowerment

KOMITE KESELAMATAN PASIEN RUMAH SAKIT KKPRS

@PERSI, 2005

Latar belakang
- Data AE di negara maju tidak kecil, WHO : data AE di rumah sakit : 3 16 % yaitu di Amerika, Australia, Inggris, Denmark dan New Zealand - Di Indonesia data AE ini masih minim - Sejak th 2000an berbagai Negara mengembangkan dan menerapkan konsep serta strategi Patient Safety dengan tujuan utama menekan AE - WHO pada th 2004 membentuk : World Alliance for Patient Safety - Menilik akan permasalahan yang terkait dengan keselamatan pasien, serta maraknya tuduhan Malpraktek di RS-RS Indonesia dan perkembangan gerakan-gerakan keselamatan pasien di dunia internasional tsb diatas, maka PERSI mengambil inisiatif untuk membentuk suatu komite yang menggerakkan dan berupaya mengangkat fokus Keselamatan Pasien di Indonesia.

Organisasi
Komite Keselamatan Pasien Rumah Sakit (KKP-RS) diangkat dan bertanggung jawab kepada Pengurus Pusat PERSI. Keanggotaan KKP-RS terdiri dari individu-individu yang berasal dari lingkungan DepKes, Rumah Sakit Pemerintah dan Swasta, serta dari berbagai organisasi a.l. IDI, PDGI, PPNI, IBI, ISFI, KARS, Fakultas Kedokteran, Konsil Kedokteran Indonesia, Yayasan Pemberdayaan Konsumen Kesehatan Indonesia, Mantan anggota DPR dsb

Visi
Meningkatnya Keselamatan Pasien dan Mutu Pelayanan Rumah Sakit

Misi * Mengangkat secara nasional Fokus Keselamatan

* Pasien Mendorong terbentuknya Kepemimpinan dan Budaya Rumah Sakit yang mencakup Keselamatan Pasien dan Peningkatan Mutu Pelayanan Mengembangkan Standar Pedoman Keselamatan Pasien berbasis riset dan pengetahuan Bekerja sama dengan berbagai Lembaga yang bertujuan meningkatkan Keselamatan Pasien dan Mutu Pelayanan Rumah Sakit

Strategi Pengembangan Keselamatan Pasien RS

Aktivitas KP-RS AE
*Sistem KP di RS *Budaya KP di RS *Kepemimpinan KP di RS -Leadership*Komitmen KP di RS *Sadar KP -Awareness-

Waktu

Kepengurusan KKP-RS Pelindung : DirJen Yan Medik Penasehat Pengurus - Ketua, Wakil Ketua - Sekretaris - Bidang Kajian Keselamatan Pasien - Bidang Program Keselamatan Pasien - Bidang Pendidikan & Latihan - Anggota

PELINDUNG Direktur Jenderal Pelayanan Medik Departemen Kesehatan RI PENASEHAT Ketua Umum PERSI PUSAT Ketua MAKERSI PUSAT Ketua KARS (Komisi Akreditasi RS) PENGURUS Ketua merangkap Anggota : Dr. Nico A. Lumenta, K. Nefro, MM Wakil Ketua I merangkap Anggota : Dr. Mgs. Johan T. Saleh, MSc Wakil Ketua II merangkap Anggota : Dr. Boedihartono, MHA Sekretaris I merangkap Anggota : DR. Rokiah Kusumapradja, SKM, MHA Sekretaris II merangkap Anggota : Dr. Luwiharsih, MSc Bidang Kajian Keselamatan Pasien Koordinator merangkap Anggota : Dr. Alex Papilaya, DTPH Wakil Koordinator merangkap Anggota : DR. Dr. Herkutanto, SpF, SH, Faclm Wakil Koordinator merangkap Anggota : Dr. Wasista Budiwaluyo, MHA Bidang Program Keselamatan Pasien Koordinator merangkap Anggota : Dr. Muki Reksoprodjo, SpOG Wakil Koordinator merangkap Anggota : Dr. Grace Frelita, MM Wakil Koordinator merangkap Anggota : Dr. HM. Natsir Nugroho, SpOG, M.Kes Bidang Pendidikan dan Pelatihan Koordinator merangkap Anggota : Dr. Robby Tandiari SpRad Wakil Koordinator merangkap Anggota : Dr. Sutoto, M.Kes

ANGGOTA Dr. Adib A. Yahya, MARS Dr. Samsi Jacobalis, SpB Dr. Farid Husain, SpB(K) Dr. G. Pandu Setiawan, SpKJ Dr. Iwan Dwiprahasto, M.Med.Sc, PhD Dr. Hermansyur Kartowisastro, SpBD Dr. H.A. Sanoesi Tambunan, SpPD,KR Dr. Koesno Martoatmodjo, SpA, MM Dr. Marius Widjajarta, SE Dr. Hanna Permana Subanegara, MARS Dr. Buddy HW Utoyo, MARS Dr. Robert Imam Sutedja H.M. Ali Taher Parasong, SH, Mhum Dr. Tjandra Y. Aditama, SpP(K), MARS Dr. Guntur Bambang Hamurwono, SpM Dr. Untung S. Suseno, M.Kes Dr. Budi Sampurna, SpF, SH Johanna Kawonal, SMIP, CV.RN Laurensia Lawintono, MSc Drg.H.Edi Sumarwanto, MM

Cakupan Tugas Bidang

Bidang Kajian Keselamatan Pasien - Pengkajian Laporan KP-RS - Riset KP-RS - Pengembangan Solusi KP-RS - Penyusunan Panduan, Pedoman, Standar, Indikator KP-RS - Penyusunan Taxonomi KP Bidang Program Keselamatan Pasien - Perencanaan & Pelaksanaan Program Komunikasi / Social Marketing - Perencanaan & Pelaksanaan Program Kerjasama dgn Pemerintah/Lembaga/Organisasi/LSM Kesehatan - Pengembangan Sistem Pelaporan KP-RS Bidang Pendidikan & Latihan - Perencanaan & Pelaksanaan Pelatihan, Lokakarya, Seminar - Penerbitan & Distrbusi Dokumen KKP-RS

Siklus Kegiatan Pokok KKP-RS

Pengkajian/Riset Belajar

Pelaporan
NM/AE

Implementasi & Measurement

YAN RS yang lebih aman

Pengembangan Solusi

Patient Involvement

Pelatihan Seminar

Panduan Pedoman Standar

Taxonomy Istilah
@PERSI, 2005

Program KKP-RS
1. Sosialisasi KKP-RS dan Konsep Keselamatan Pasien : presentasi di berbagai Pertemuan Nasional Organisasiorganisasi Kesehatan, Asosiasi Fakultas Kedokteran & Fakultas Keperawatan, LSM Kesehatan di Indonesia, Asosiasi Perusahaan Asuransi, MNC, dsb (Seminar Nasional PERSI Agustus 2005 : ceramah KP, KKP-RS & beberapa produknya) 2. Pembentukan Sistem Pelaporan AE di rumah sakit : laporan bersifat anonim dan rahasia 3. Pengkajian, Riset, Analisis / belajar, dari kasus-kasus yang ada 4. Pengembangan dan Publikasi : Solusi, Panduan, Pedoman, Standar, Indikator - Keselamatan Pasien

Program KKP-RS (2)

5. Implementasi Standar Keselamatan Pasien melalui Pelatihan-pelatihan, Lokakarya, melalui KARS (Komisi Akreditasi Rumah Sakit) dsb 6. Pengembangan Kerjasama dgn Pemerintah /Lembaga /Organisasi /LSM Kesehatan 7. Pengembangan Taksonomi : Konsep, Prinsip, Norma, Istilah dalam bidang Keselamatan Pasien

Potensi Kendala / Hambatan

* Inisiatif & Prosedur Pelaporan Near Miss/Adverse Event * Pelaporan NM / AE oleh RS-RS ke KKP-RS * Partisipasi Kelompok Dokter khususnya yg di RS * Pencetakan-Penyebaran Publikasi/Brosur Pedoman

Lain-lain
* KKP-RS bukan badan Regulator, Investigatif * Dukungan DepKes, DinasKes, RS, kalangan Profesi Kesehatan, LSM Kesehatan

Kesimpulan
1) Di Indonesia Konsep Patient Safety / Keselamatan Pasien yang komprehensif belum banyak dikenal. 2) Bagian-bagiannya sudah dilaksanakan a.l.: Pinok, K3 (Keselamatan Kerja, Kebakaran, Kewaspadaan Bencana), , Informed consent, Audit Klinis, Risk Management 3) Proses2 di kawasan Blaming dgn maraknya tuduhan malpraktek melelahkan & merugikan semua pihak. 4) Dengan terbentuknya Komite Keselamatan Pasien Rumah Sakit (KKP-RS) pd th 2005, Indonesia praktis belum tertinggal dalam upaya menolong masyarakat Perumahsakitan dan Konsumennya menekan AE, keluar dari situasi Medical Error yang berbias ke Malpraktek. Disadari kendala akan cukup berat, butuh partisipasi berbagai organisasi & LSM kesehatan 5) Fokus Nasional di bidang Kesehatan yg besar/menonjol: * Keluarga Berencana * Keselamatan Pasien (?)

Terimakasih

Atas perhatiannya

Komite Keselamatan Pasien Rumah Sakit PERSI Dr. Nico A. Lumenta, K.Nefro, MM