FORM A.

SENSUS HARIAN INDIKATOR SASARAN MUTU

UNIT : ANESTESI
JUDUL INDIKATOR AREA : Angka Kesalahan (KTC, KTD, Sentinel) Penggunaan
Obat High
Allert

BULAN
TAHUN :
AREA MONITORING
:
SUMBER DATA
: BEDAH SENTRAL
: Check list ruangan dan laporan insiden dari KPRS /
SAMPLE SIZE
rekapitulasi
laporan insiden dari ruangan
: 100 %
Tangg Numerator Denumerator
al
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Jumla
h

Pangkalan
Bun, ............................................
Verifikator Indikator mutu utama/
Indikator mutu unit Penanggungjawab
Kepala bagian/Kasi/Karu/Kepala
instalasi-penanggungjawab unit
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FORM B. LAPORAN BULANAN DARI UNIT KE KOMITE MUTU

Nama Unit : ANESTESI

Indikator Sasaran Mutu : Angka Kesalahan (KTC, KTD, Sentinel) Penggunaan
Obat High
Allert

Area : BEDAH SENTRAL

Numerator : Kesalahan penggunaan obat high allert yang
dipakai di Unit
Anestesi
Denumerator : Jumlah total penggunaan obat high allert di Unit
Anestesi
dengan teknik 6 (enam) benar
Formula : Numerator
----------------- x 100 % = ------------------------- x
100 %
Denumerator
Target : 0 (nol)
Hasil indikator mutu unit :
Kesimpulan : TERCAPAI / TIDAK TERCAPAI *)

Analisa unit : (Tercapai / tidak tercapai /, alasan *)

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Rekomendasi :

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Pangkalan Bun, ..............................................

Penanggungjawab Verifikator Komite mutu

Kepala bagian/Kasi/Karu/Kepala instalasi- (Ketua/Wakil Ketua/Sekretaris/*)
penanggungjawab unit/*)

(......................................) (......................................)

*) coret yang tidak perlu