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DAFTAR ISI

KATA PENGANTAR .................................................................................................... i


DAFTAR ISI ................................................................................................................ii
BAB I PENDAHULUAN ................................................................................ 1
A. Latar Belakang ..................................................................................................... 1
B. Gambaran Umum Komite PMKP ........................................................................ 1
1. Struktur Organisasi ......................................................................................... 2
BAB II HASIL KEGIATAN .............................................................................. 3
A. Indikator Mutu Unit (Area Manajemen dan Area Klinis) .................................... 3
1. Rawat Inap...................................................................................................... 3
2. Kamar Operasi................................................................................................ 3
3. Kebidanan....................................................................................................... 3
4. Radiologi ........................................................................................................ 4
5. Laboratorium .................................................................................................. 5
6. Tumbuh Kembang Anak (TKA) dan Fisioterapi ........................................... 5
7. Fisioterapi ....................................................................................................... 5
8. Farmasi ........................................................................................................... 5
9. Sanitasi ........................................................................................................... 6
10. Teknisi ............................................................................................................ 7
11. Pencegahan dan Pengendalian Infeksi Surveilance dan Pelaporan ................ 8
12. Humas dan Marketing .................................................................................. 10
13. Administrasi ................................................................................................. 11
14. Hemodialisa .................................................................................................. 11
15. Keuangan ...................................................................................................... 13
B. Indikator Area Manajerial Lainnya .................................................................... 13
1. Ketepatan Pelaporan RL............................................................................... 13
2. Kejadian Tertusuk Jarum ............................................................................. 14
3. Laporan 10 Besar Penyakit .......................................................................... 14
4. Kepatuhan Penggunaan Alat Pelindung Diri (APD) .................................... 15
C. Indikator Area Klinis Lainnya............................................................................ 15
1. Penulisan Resep Obat Sesuai Formularium ................................................. 15
2. Kejadian Nyaris Cidera Peresepan Obat ...................................................... 16

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3. Angka Insiden Plebitis ................................................................................. 16
D. Penelitian Dengan Ethical Clearance ................................................................ 17
E. Indikator Sasaran Keselamatan Pasien ............................................................... 17
F. Indikator International Library .......................................................................... 19
G. Insiden Keselamatan Pasien ............................................................................... 19
BAB III RENCANA PROGRAM KERJA DAN KEGIATAN
TRISEMESTER KEDUA TAHUN 2018 ......................................... 21
BAB IV PENUTUP........................................................................................... 23

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