PATIENT SAFETY

Ns. ANSHAR BONAS SILFA, S.Kep.

Staf IBS RSUP DR.M.DJAMIL PADANG
WELCOME
 PENDAHULUAN

SAFETY

QUALITY
PATIENT SAFETY
suatu sistem dimana rumah sakit membuat asuhan
pasien lebih aman, mencegah terjadinya cidera y/
disebabkan o/ kesalahan akibat melaksanakan
suatu tindakan atau tdk mengambil tindakan y/
PATIENT SAFETY

• Pengenalan Resiko,
• Identifikasi dan Pengelolaan Hal Y/
Berhubungan dg Resiko Pasien,
• Pelaporan dan Analisis Insiden,
• Kemampuan Belajar dari Insiden,
• Tindak Lanjut dan Implementasi
Solusi U/ Meminimalkan Resiko
(Depkes 2008)
 PATIENT SAFETY
• Sistem Ini Mencegah Terjadinya Cedera Yg Disebabkan Oleh
Kesalahan Akibat Melaksanakan Suatu Tindakan Atau Tidak
Mengambil Tindakan Yg Seharusnya Diambil.

• Dimasukkan Dalam Instrumen Akreditasi RS (INSTRUMEN

2007)

• Mulai diberlakukan tahun 2008

• Laporan Insiden RS/PUSKESMAS

(Kejadian yg tidak diharapkan / KTD)
TUJUAN
• Menciptakan budaya
keselamatan pasien di
rumah sakit,
• Meningkatkan
akuntabilitas rumah
sakit,
• Menurunkan KTD di
rumah sakit,
• Terlaksananya
program-program
pencegahan sehingga
tidak terjadi
pengulangan kejadian
tidak diharapkan
 KESELAMATAN PASIEN MERUPAKAN
MASALAH PENTING DALAM SEBUAH
RUMAH SAKIT
• Diperlukan standar keselamatan
sebagai acuan bagi rumah sakit di
Indonesia
• Mengacu pada “Hospital Patient Safety
Standards” y/dikeluarkan o/ Join
Commision on Accreditation of Health
Organization di Illinois tahun 2002
• Disesuaikan dg situasi dan kondisi di
Indonesia.
• PENILAIAN y/ dipakai Indonesia
menggunakan instrumen Akreditasi
Rumah Sakit y/ dikeluarkan o/ KARS.
Panduan Nasional Keselamatan Pasien Rumah Sakit
(Patient Safety) (Depkes RI 2002)
Terdiri dari dari 7 standar:
• Hak pasien Bebas memilih
Unit Layanan
dan

• Mendididik pasien dan keluarga Tenaga Kesehatan

• Keselamatan pasien dan Berhak

Berhak
Menyetujui/tdk
Mengadu InformConcent
kesinambungan pelayanan Atas
kerugian
dgn jelas

• Penggunaan metoda metoda pe kinerja HAK PASIEN

u/ melakukan evaluasi dan program pe

 keselamatan pasien
Bebas
Bebas memilih
dari perlakuan
Jenis Layanan
diskriminatif
Kesehatan
• Peran kepemimpinan dlm me  Yg ditawarkan

keselamatan pasien Berhak

• Mendidik staf tentang keselamatan mendapatkan

Ganti Rugi
Berhak
Atas
Kerahasiaan
pasien Pribadinya

• Komunikasi merupakan kunci bagi staf

’Tujuh Langkah Menuju Keselamatan
Pasien Rumah Sakit’
• Bangun kesadaran akan nilai
keselamatan pasien
• Pimpin dan dukung staf
• Integrasikan aktivitas
pengelolaan risiko
• Kembangkan sistem pelaporan
• Libatkan dan berkomunikasi
dengan pasien
• Belajar dan berbagi pengalaman
tentang keselamatan pasien
• Cegah cedera melalui
implementasi sistem
keselamatan pasien
 ELEMENT OF PATIENT SAFETY
• Adverse drug events(ADE)/ medication
errors (ME)
• Restraint use
• Nosocomial infections
• Surgical mishaps
• Pressure ulcers
• Blood product safety/administration
• Antimicrobial resistance
• Immunization program
• Falls
• Blood stream - vascular catheter care
• Systematic review, follow-up, and reporting
of patient/visitor incident reports
 PATIENT SAFETY PROBLEM
• Transfussion error
• Adverse Drug Event
• Wrong-site surgery
• Surgical injuries & Needle Stick Injuries
• Hosp-acquired infection
• Falls
• Burns
• Mistaken Identity
MOST COMMON ROOT CAUSES OF ERRORS
• Communication problems
• Inadequate information flow
• Human problems
• Patient-related issues
• Organizational transfer of
knowledge
• Staffing patterns/work flow
• Technical failures
• Inadequate policies and
procedures
(AHRQ Publication No. 04-RG005,
December 2003. ) Agency for
Healthcare Research and Quality
INTERNATIONAL PATIENT SAFETY GOALS
 NURSING AWARENESS
Perawat bertanggung jawab dalam:
• Memberikan informasi pd pasien dan keluarga tentang kemungkinan-2
resiko
• Melaporkan kejadian tak diharapkan kpd y/ berwenang
• Peran Aktif dlm melakukan pengkajian terhadap keamanan dan mutu
pelayanan
• Me komunikasi dg pasien dan nakes professional lain
• Mengusulkan pe  kemampuan staf yang cukup
• Membantu pengukuran terhadap peningkatan patient safety
• Me  standar baku program pengendalian infeksi (infection control)
• Mengusulkan SOP dan protocol pengobatan y/ dpt me(-) kejadian error
• Berhubungan dengan badan-2 profesional y/ mewakili para dokter ahli
farmasi dll
• Me  cara pengemasan dan pelabelan obat
• Berkolaborasi dg sistem pelaporan nasional u/ mencatat, menganalisa dan
mempelajari kejadian-2 tak diharapkan
• Mengembangkan mekanisme pen kesadaran, sebagai contoh u/
pelaksanaan akreditasi
• Karakteristik dari pemberi pelayanan kesehatan menjadi tolok ukur
terhadap excellence dalam patient safety
 QUALITY WORKPLACES = QUALITY PATIENT CARE
• Mengembangkan PERANAN KEPERAWATAN
• Ruang lingkup praktek keperawatan --PROSES
EVOLUSI PADA PROFESI
• PROFESIONAL DAN REMUNERASI
• Mengembangkan sikap tentang pentingnya
LINGKUNGAN KERJA YANG AMAN
• DISIPLIN LAIN terlibat dlm pengembangan
kebijakan lingkungan kerja yang aman
• Mendukung PENELITIAN
• Mendorong LEMBAGA PENDIDIKAN untuk
meningkatkan penekanan pada teori kerja sama tim
• PENGHARGAAN kepada fasilitas kesehatan yg
menunjukkan EFEKTIVITAS PRAKTIK LINGKUNGAN
POSITIF
• Sebagai TOOL KIT untuk memberikan informasi
tentang pentingnya lingkungan kerja yang positif
 PENDEKATAN KOMPREHENSIF DALAM
PENGKAJIAN KESELAMATAN PASIEN
• Struktur
– Kebijakan dan prosedur organisasi :
– Fasilitas
– Persediaan
• Lingkungan
– Pencahayaan dan permukaan
– Temperature
– Kebisingan
– Ergonomic dan fungsional : ergonomic berpengaruh terhadap
penampilan seperti teknik memindahkan pasien, jika terjadi
kesalahan dapat menimbulkan pasien jatuh atau cedera.
 PENDEKATAN KOMPREHENSIF DALAM PENGKAJIAN
KESELAMATAN PASIEN lanjutan…
• Peralatan dan teknologi
– Fungsional : penggunaan alat dan desain dari alat.-pelatihan
untuk mengoperasikan alat secara tepat dan benar .
– Keamanan : Alat – alat yang digunakan juga harus didesain
penggunaannya dapat meningkatkan keselamatan pasien.
• Proses
– Desain kerja : Untuk mencegahkesalahan tersebut harus
dilakukan research based practice yang diimplementasikan.
– Karakteristik risiko tinggi : perlu dibuat suatu system pengingat
untuk mengurangi kesalahan
– Waktu :
– Perubahan jadual dinas perawat.
– Waktu juga sangat berpengaruh pada saat pasien harus dilakukan
tindakan diagnostic atau ketepatan pengaturan pemberian obat
– Efisiensi : keterlambatan diagnosis atau pengobatan ------
pembiayaan yang harus di tanggung oleh pasien.
PENDEKATAN KOMPREHENSIF DALAM PENGKAJIAN
KESELAMATAN PASIEN lanjutan…

• Orang
– Sikap dan motivasi.
– Kesehatan fisik
– Kesehatan mental dan emosional
– Faktor interaksi manusia dengan teknologi dan lingkungan :
pendidikan atau pelatihan
– Faktor kognitif , komunikasi dan interpretasi
• Budaya
– bepengaruh besar thd pemahaman kesalahan dan
keselamatan pasien.
– Pilosofi tentang keamanan ; keselamatan pasien
– Jalur komunikasi
– Budaya melaporkan vs Budaya menyalahkan (Blaming)
– Staff –system kepemimpinan dan budaya merencanakan staf,
membuat kebijakan dan mengantur personal termasuk jam
kerja, beban kerja, manajemen kelelahan, stress dan sakit
 “Nine Life Saving Patient Safety Solutions”
WHO Collaborating Centre for Patient Safety May 2nd, 2007

• Perhatikan Nama Obat, Rupa dan Ucapan Mirip

(Look-Alike, Sound-Alike Medication Names).
• Pastikan Identifikasi Pasien
• Komunikasi Secara Benar saat Serah Terima /
Pengoperan Pasien
• Pastikan Tindakan yang benar pada Sisi Tubuh
yang benar
• Kendalikan Cairan Elektrolit Pekat
(concentrated).
• Pastikan Akurasi Pemberian Obat pada
Pengalihan Pelayanan
• Hindari Salah Kateter dan Salah Sambung Slang
(Tube)
• Gunakan Alat Injeksi Sekali Pakai
• Tingkatkan Hand hygiene u/ PENCEGAHAN
lnfeksi Nosokomial
 WRONG - SITE SURGERY
• Pembedahan merupakan salah satu area pelayanan kesehatan yang mudah
menimbulkan kejadian medical error tetapi dengan mudah pula dapat dicegah.
• Kasus-kasus dengan pelaksanaan prosedur yang keliru atau pembedahan sisi
tubuh yang salah sebagian besar adalah akibat dan miskomunikasi dan tidak
adanya informasi atau informasinya tidak benar.
• Faktor yang paling banyak kontribusinya terhadap kesalahan-kesalahan
macam ini adalah tidak ada atau kurangnya proses pra-bedah yang
distandardisasi.
• Rekomendasi:
– proses verifikasi prapembedahan;
– pemberian tanda pada sisi yang akan dibedah oleh petugas yang akan
melaksanakan prosedur ; dan
– Prosedur ’Time out” sesaat sebelum memulai prosedur untuk :
• mengkonfirmasikan identitas pasien,
• prosedur dan sisi yang akan dibedah.
 Causes of Wrong-Site Surgeries
System Factors Process Factors
• Lack of institutional controls/formal system to verify the •  Inadequate patient assessment
correct site of surgery • Inadequate care planning
• Lack of a checklist to make sure every check was performed
• Inadequate medical record review
• Exclusion of certain surgical team members
• Miscommunication among members of the
• Reliance solely on the surgeon for determining the correct
surgical site surgical team and the patient
• Unusual time pressures (e.g., unplanned emergencies or • More than one surgeon involved in the
large volume of procedures) procedure
• Pressures to reduce preoperative preparation time • Multiple procedures on multiple parts of a
• Procedures requiring unusual equipment or patient patient performed during a single operation
positioning • Failure to include the patient and family or
• Team competency and credentialing significant others when identifying the
• Availability of information correct site
• Organizational culture • Failure to mark or clearly mark the correct
• Orientation and training operation site
• Staffing
• Incomplete or inaccurate communication
• Environmental safety/security
among members of the surgical team
• Continuum of care
• Noncompliance with procedures
• Patient characteristics, such as obesity or unusual anatomy,
that require alterations in the usual positioning of the • Failure to recheck patient information
patient before starting the operation
Universal Protocol for Preventing Wrong-Site
Surgery 1
• Preoperative verification process
– Verification of the correct person, procedure, and site should
occur (as applicable):
• At the time the surgery/procedure is scheduled.
• At the time of admission or entry into the facility.
• Anytime the responsibility for care of the patient is transferred to another
caregiver.
• With the patient involved, awake, and aware, if possible.
• Before the patient leaves the preoperative area or enters the
procedure/surgical room.
– A preoperative verification checklist may be helpful to ensure
availability and review of the following, prior to the start of the
procedure:
• Relevant documentation (e.g., history and physical, consent).
• Relevant images, properly labeled and displayed.
• Any required implants and special equipment.
 Universal Protocol for Preventing Wrong-Site
Surgery 2
• Marking the operative site
– Make the mark at or near the incision site. Do NOT mark any nonoperative site(s) unless necessary for some
other aspect of care.
– The mark must be unambiguous (e.g., use initials or "YES" or a line representing the proposed incision;
consider that "X" may be ambiguous).
– The mark must be positioned to be visible after the patient is prepped and draped.
– The mark must be made using a marker that is sufficiently permanent to remain visible after completion of
the skin prep. Adhesive site markers should not be used as the sole means of marking the site.
– The method of marking and type of mark should be consistent throughout the organization.
– At a minimum, mark all cases involving laterality, multiple structures (fingers, toes, lesions), or multiple
levels (spine). Note: In addition to preoperative skin marking of the general spinal region, special
intraoperative radiographic techniques are used for marking the exact vertebral level.
– The person performing the procedure should do the site marking.
– Marking must take place with the patient involved, awake, and aware, if possible.
– Final verification of the site mark must take place during the "time out."
– A defined procedure must be in place for patients who refuse site marking.
• Exemptions
– Single organ cases (e.g., Cesarean section, cardiac surgery).
– Interventional cases for which the catheter/instrument insertion site is not predetermined (e.g., cardiac
catheterization).
– Teeth–but, indicate operative tooth name(s) on documentation or mark the operative tooth (teeth) on the
dental radiographs or dental diagram.
– Premature infants, for whom the mark may cause a permanent tattoo.
 Universal Protocol for Preventing Wrong-Site
Surgery
• "Time out" immediately before starting the procedure Must be conducted in the
location where the procedure will be done, just before starting the procedure. It must
involve the entire operative team, use active communication, be briefly documented,
such as in a checklist (the organization should determine the type and amount of
documentation), and must, at the least, include:
– Correct patient identity.
– Correct side and site.
– Agreement on the procedure to be done.
– Correct patient position.
– Availability of correct implants and any special equipment or special
requirements.
–  
The organization should have processes and systems in place for reconciling
differences in staff responses during the "time out."
• Procedures for non-OR settings, including bedside procedures
– Site marking must be done for any procedure that involves laterality, multiple
structures, or levels (even if the procedure takes place outside of an OR).
– Verification, site marking, and "time out" procedures should be as consistent as
possible throughout the organization, including the OR and other locations where
invasive procedures are done.
– Exception: Cases in which the individual doing the procedure is in continuous
attendance with the patient from the time of decision to do the procedure and
consent from the patient through to the conduct of the procedure may be
exempted from the site marking requirement. The requirement for a "time out"
 TIME OUT
• Immediately before starting the procedure
– Purpose: To conduct a final verification of the correct
patient, procedure, site and, as applicable, implants.
– Process: Active communication among all members
of the surgical/procedure team, consistently initiated
by a designated member of the team, conducted in a
"fail-safe" mode, i.e., the procedure is not started until
any questions or concerns are resolved
• Must be conducted in the location where the procedure will be
done, just before starting the procedure. It must involve the
entire operative team, use active communication, be briefly
documented, such as in a checklist (the organization should
determine the type and amount of documentation), and must,
at the least, include:
– Correct patient identity.
– Correct side and site.
– Agreement on the procedure to be done.
– Correct patient position.
– Availability of correct implants and any special equipment
or special requirements.
 Alw
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was
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your
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 TERIMA KASIH

LEARN FROM EVERYONE, BUT FOLLOW NO ONE