DAFTAR ISI

PEDOMAN PELAYANAN ANESTESIOLOGI DAN TERAPI INTENSIF

I. Bab I ................................................................................................................................. 1

II. Tujuan ............................................................................................................................. 1

III. Ruang Lingkup ................................................................................................................ 1

IV. Prinsip ............................................................................................................................. 1

V. Kewajiban Dan Tanggung Jawab ..................................................................................... 2

1. Seluruh Staf Rumah Sakit ..................................................................................... 2

2. SDM Yang Bertugas (Petugas Tempat Pendaftaran Pasien/Perawat

Penanggung

Jawab Pasien) ........................................................................................................ 2

3. Kepala Unit/Kepala Ruangan................................................................................ 2

4. Pengawas Keperawatan......................................................................................... 2

VI. Tatalaksana Identifikasi .................................................................................................. 3

1. Tatalaksana Gelang Identifikasi Pasien ................................................................ 3

2. Tindakan/Prosedur Yang Membutuhkan Identifikasi ........................................... 5

3. Tatalaksana Identifikasi Pasien Pada Pemberian Obat-Obatan ............................ 6

4. Tatalaksanan Identifikasi Pasien Yang Menjalani Pemeriksaan radiologi ........... 6

5. Tatalaksana Identifikasi Pasien Yang Menjalani Tindakan Operasi .................... 7

6. Tatalaksana Identifikasi Pasien Yang Akan Dilakukan Pengambilan dan

Pemberian

Darah (Transfusi Darah) ....................................................................................... 7

7. Tatalaksana Identifikasi Pada Bayi Baru Lahir/Neonatus .................................... 7

8. Tatalaksana Identifikasi Pasien Rawat Jalan ........................................................ 8

 9. Tatalaksana Identifikasi Nama Pasien Yang Sama Di ruangan Rawat Inap ......... 8

10. Tatalaksana Identifikasi pasien Yang Identitasnya Tidak Di Ketahui .................. 8

11. Tatalaksana Identifikasi Pasien Dengan Gangguan Jiwa...................................... 8

12. Tatalaksana Identifikasi Pasien Yang Meninggal ................................................. 9

VII. Macam-Macam Gelang Identifikasi .............................................................................. 9

VIII. Macam-Macam Stiker Identifikasi ............................................................................... 9

IX. Melepas Gelang Dan Stiker Identifikasi ......................................................................... 10

X. Pelaporan Insiden/Kejadian Kesalahan Identifikasi Pasien.............................................. 10

XI. Revisi Dan Audit ............................................................................................................. 12

ALGORITMA IDENTIFIKASI PASIEN ......................................................................... 13

AUDIT GELANG PENGENAL PADA PASIEN RAWAT INAP .................................. 14

DAFTAR PUSTAKA .......................................................................................................... 15

 DAFTAR ISI

PEDOMAN IDENTIFIKASI PASIEN

BAB I PENDAHULUAN .................................................................................................... 1

A. Latar Belakang........................................................................................................... 1

B. Tujuan ........................................................................................................................ 1

1. Tujuan Umum ...................................................................................................... 1

2. Tujuan Khusus ..................................................................................................... 1

C. Ruang Lingkup Pedoman Pelayanan ......................................................................... 2

D. Batasan Operasional .................................................................................................. 2

E. Landasan Hukum ....................................................................................................... 2

BAB II STANDART KETENAGAAN ............................................................................. 4

Kualifikasi Sumber Daya Manusia ............................................................................. 4

BAB III STANDART FASILITAS .................................................................................... 5

A. Di Tempat Pendaftaran Pasien dan Unit Rekam Medis ............................................ 5

B. Di Unit Rawat Inap .................................................................................................... 5

C. Di Unit Rawat Jalan ................................................................................................... 5

BAB IV TATALAKSANA PELAYANAN ........................................................................ 6

A. Prosedur Pemakaian Gelang Pengenal ...................................................................... 6

B. Warna Pada Gelang ................................................................................................... 8

C. Prosedur Yang Membutuhkan Identifikasi Pasien Dengan Benar ............................ 8

D. Identifikasi Pasien Yang Menjalani Prosedur Pemeriksaan Radiologi ..................... 9

E. Identifikasi Pasien Yang Menjalani Tindakan Operasi ............................................. 9

F. Prosedur Pengambilan dan Pemberian Produk/Komponen Darah ............................ 9

 G. Prosedur Identifikasi Pada Bayi Baru Lahir/Neonatus .............................................. 10

H. Identifikasi Pasien Rawat Jalan ................................................................................. 10

I. Identifikasi Pasien Dengan Nama Yang Sama Diruang Perawatan .......................... 10

J. Prosedur Pasien Yang Identitasnya Tidak Diketahui ................................................ 10

K. Prosedur Identifikasi Pasien Dengan Gangguan Jiwa ............................................... 11

L. Identifikasi Pasien Yang Meninggal.......................................................................... 11

M. Prosedur Melepas Gelang Identitas ........................................................................... 11

BAB V LOGISTIK .............................................................................................................. 13

BAB VI KESELAMATAN PASIEN ................................................................................. 14

A. Sasaran Keselamatan Pasien ...................................................................................... 14

BAB VII KESELAMATAN KERJA ................................................................................. 15

A. Keselamatan dan Keamanan ...................................................................................... 15

BAB VIII PENGENDALIAN MUTU ................................................................................ 16

Indikator Mutu Identifikasi Pasien ............................................................................ 16

BAB IX PENUTUP.............................................................................................................. 17
 DAFTAR ISI

PANDUAN TEKNIK KOMUNIKASI EFEKTIF

BAB I DEFENISI ............................................................................................................. 1

BAB II RUANG LINGKUP .............................................................................................. 2

A. Ruang Lingkup ................................................................................................... 2

B. Batasan Operasional............................................................................................. 2

C. Landasan Hukum ................................................................................................ 3

BAB III TATALAKSANA KOMUNIKASI ..................................................................... 4

A. Proses Komunikasi ............................................................................................. 4

B. Teknik Komunikasi Efektif ................................................................................ 4

C. Macam-Macam Teknik Komunikasi Efektif ...................................................... 7

1. Teknik Komunikasi Efektif Antara Pribadi ................................................... 7

2. Teknik Komunikasi Efektif Antara Dokter dan Pasien ................................. 8

3. Teknik Komunikasi Efektif Antara Tenaga Kesehatan ................................. 10

4. Teknik Komunikasi Efektif di Rumah Sakit Umum Sylvani ........................ 10

5. Pelaporan Hasil Pemeriksaan Kritis............................................................... 13

6. Pelaporan Pemeriksaan CITO ........................................................................ 16

7. Alur Pelaporan Nilai Kritis dan Penunjang ................................................... 16

8. Mekanisme Pelaporan Hasil Pemeriksaan Kritis dan CITO .......................... 16

D. Teknik Berbicara Efektif ................................................................................... 16

E. Teknik Mendengar Efektif .................................................................................. 17

BAB IV DOKUMENTASI .................................................................................................. 18

DAFTAR PUSTAKA ......................................................................................................... 19

 DAFTAR ISI

PANDUAN HIGH ALERT MEDICATIONS (OBAT-OBATAN DENGAN

PENGAWASAN)

I. TUJUAN .................................................................................................................. 1

II. DEFENISI ............................................................................................................... 1

III. KEBIJAKAN .......................................................................................................... 1

IV. PRINSIP .................................................................................................................. 3

V. PROSEDUR ............................................................................................................ 4

1. Peresepan ......................................................................................................... 4

2. Persiapan dan Penyimpanan ............................................................................. 4

3. Pemberian Obat ................................................................................................ 5

VI. HIGH ALERT MEDICATION............................................................................. 9

1. Alkaloid Vinca ................................................................................................ 9

2. Agonis Adrenergik IV ...................................................................................... 10

3. Antagonis Adrenergik ..................................................................................... 10

4. Dopamin dan Dobutamin ................................................................................. 10

5. Kalsium Intravena ............................................................................................ 10

6. Insulin IV.......................................................................................................... 11

7. Konsentrat Elektrolit Injeksi ............................................................................ 11

8. Infus Narkose/Opiat ......................................................................................... 12

9. Agen Sedasi IV................................................................................................. 13

10. Infus Magnesium Sulfat ................................................................................... 13

 11. Obat-Obat Inotropik IV .................................................................................... 13

12. Garam Fosfat ................................................................................................... 13

PEMBERIAN HIGH ALERT MEDICATION PADA PEDIATRIKDAN

NEONATUS

TABEL

1. Obat-Obatan dalam Kategori High Alert Medications .............................................. 2

2. Konsentrasi Standar Obat-Obatan Untuk Pediatrik ................................................... 15

3. Daftar Obat LASA (Look Alike Sound Alike) .......................................................... 16

4. Daftar Obat HIGH ALERT MEDICATION ............................................................. 18

REFERENSI ........................................................................................................................ 19
 DAFTAR ISI

PANDUANTEPAT LOKASI,TEPAT PROSEDUR, DAN TEPAT PASIEN

OPERASI

BAB I DEFENISI ............................................................................................................. 1

BAB II RUANG LINGKUP .............................................................................................. 2

A. Ruang Lingkup ................................................................................................... 2

B. Prinsip ................................................................................................................. 2

C. Kewajiban dan Tanggung Jawab ........................................................................ 2

BAB III TATALAKSANA.................................................................................................. 3

A. Tatalaksana Pada Tepat Lokasi,Tepat Prosedur, Serta Tepat Pasien Yang

Akan Menjalani Operasi .................................................................................... 3

B. Analisis Kelengkapan Daftar Titik Operasi ...................................................... 7

C. Pelaporan Insiden/ Kejadian Kesalahan Lokasi, Prosedur dan Pasien Yang

Akan Dilakukan Tindakan Operasi ................................................................... 7

D. Revisi dan Audit ................................................................................................ 8

BAB IV DOKUMENTASI .................................................................................................. 9

 DAFTAR ISI

PANDUAN PENGAPLIKASIAN RESTRAINT DAN ISOLASI/ PENGASINGAN

TERHADAP PASIEN

I. PENDAHULUAN .................................................................................................. 1

II. TUJUAN ................................................................................................................. 1

III.DEFENISI....................................................................................................................... 1

IV.JENIS RESTRAINT ...................................................................................................... 2

1. Pembatasan Fisik ................................................................................................ 2

2. Pembatasan Mekanik .......................................................................................... 3

3. Surveilans Teknologi .......................................................................................... 4

4. Pembatasan Kimia .............................................................................................. 5

5. Pembatasan Psikologis ....................................................................................... 6

V. INDIKASI .............................................................................................................. 7

VI. DAMPAK NEGATIF PENGGUNAAN RESTRAINT .................................... 9

VII.ASPEK ETIS ....................................................................................................... 9

VIII. ASPEK HUKUM .............................................................................................. 11

IX. PERSETUJUAN INFORMED CONCERNT .................................................. 14

X. KENDALI/KONTROL JALAN KELUAR DAN KE DALAM GEDUNG ... 14

XI. PEMBERIAN DUKUNGAN DARI ORGANISASI/PEMILIK ..................... 15

XII.TANGGUNG JAWAB INDIVIDU .................................................................. 16

XIII. PANDUAN ........................................................................................................ 17

XIV. EVALUASI PANDUAN/KEBIJAKAN .......................................................... 25

LAMPIRAN

I. SKEMA IMPLEMENTASI RESTRAINT .................................................. 27

II. FORMULIR APLIKASI RESTRAINT/ISOLASI ........................................ 28

III. PANDUAN INTERFENSI RESTRAINT / ISOLASI DAN

ALTERNATIF ............................................................................................... 30

REFERENSI .............................................................................................................. 31
 DAFTAR ISI

PEDOMAN MANAJEMEN RISIKO JATUH

BAB I PENDAHULUAN ...................................................................................................

A. Latar Belakang .....................................................................................................

B. Tujuan ..................................................................................................................

1. Tujuan Umum ..................................................................................................

2. Tujuan Khusus..................................................................................................

C. Ruang Lingkup Pedoman Pelayanan ....................................................................

D. Batasan Operasional ..............................................................................................

BAB II STANDART KETENAGAAN

A. Kualifikasi Sumber Daya Manusia .....................................................................

BAB III STANDAR FASILITAS

A. Kualifikasi Sumber Daya Manusia ...........................................................................

III.DEFENISI....................................................................................................................... 1

IV.JENIS RESTRAINT ...................................................................................................... 2

6. Pembatasan Fisik ................................................................................................ 2

 7. Pembatasan Mekanik .......................................................................................... 3

8. Surveilans Teknologi .......................................................................................... 4

9. Pembatasan Kimia .............................................................................................. 5

10. .............................................................................................................. P

embatasan Psikologis .......................................................................................... 6

V. INDIKASI .............................................................................................................. 7

VI. DAMPAK NEGATIF PENGGUNAAN RESTRAINT .................................... 9

A. ASPEK ETIS ....................................................................................................... 9

B. ASPEK HUKUM ................................................................................................ 11

C. PERSETUJUAN INFORMED CONCERNT .................................................. 14

D. KENDALI/KONTROL JALAN KELUAR DAN KE DALAM GEDUNG ... 14

E. PEMBERIAN DUKUNGAN DARI ORGANISASI/PEMILIK ..................... 15

F. TANGGUNG JAWAB INDIVIDU .................................................................. 16

G. PANDUAN .......................................................................................................... 17

H. EVALUASI PANDUAN/KEBIJAKAN ............................................................ 25