PEMERINTAH KABUPATEN MALANG

DINAS KESEHATAN
UPTD PUSKESMAS TUREN
Jl. Panglima Sudirman 210 Turen Telp. 0341-824214
Email: puskturen@yahoo.com
MALANG

FORMULIR LAPORAN INSIDEN KESELAMATAN PASIEN

Di FASILITAS PELAYANAN KESEHATAN
PUSKESMAS TUREN

LAPORAN INSIDEN
(INTERNAL)

RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAKSIMAL 2X24 JAM

1. Data Korban:
Nama :
No. RM : Ruangan :
Umur :
Kelompok Umur :
 0-1 bulan
 >1 tahun – 5 tahun
 > 15 tahun – 30 tahun
 > 65 tahun
 >1 bulan – 1 tahun
 > 5 tahun – 15 tahun
 > 30 tahun – 65 tahun
Jenis Kelamin : Laki-Laki Perempuan
Penanggung biaya pasien :
 pribadi
 pemerintah
 BPJS

2. Rincian Kejadian
Tanggal :
Waktu :

Insiden :

Kronologi :
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Jenis Insiden :
o Kejadian Nyaris Cedera / KNC
o Kejadian Tidak Cedera / KTC
o Kejadian Tidak Diharapkan / KTD

Orang pertama yang melaporkan:

o Karyawan : dokter / Perawat / Bidan / Petugas Lainnya
o Pasien
o Keluarga pasien
o Pengunjung
o Lain-lain
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Insiden terjadi pada:
o Pasien
o Lain-lain
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Insiden menyangkut pasien:
o Pasien rawat inap
o Pasien rawat jalan
o Pasien UGD
o Lain-lain
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 Tempat kejadian:

Unit terkait yang menyebabkan insiden:

Akibat insiden terhadap pasien:

o Kematian
o Cedera berat
o Cedera sedang
o Cedera ringan
o Tidak ada cedera

Tindakan segera yang dilakukan setelah kejadian, dan hasilnya:

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Tindakan dilakukan oleh:

o Tim, terdiri dari ...............................................................................
o Dokter
o Perawat
o Bidan
o Petugas lainnya ..............................................................................
Apakah kejadian yang sama pernah terjadi di unit kerja yang lain?
o Ya
Waktu kejadian:
Langkah atau tindakan yang telah diambil pada unit kerja
tersebut untuk mencegah berulangnya kejadian yang
sama:...............................................................................................
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o Tidak

Pembuat Laporan Penerima Laporan

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Tanggal Terima: Tanggal Terima:
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