LAPORAN INSIDEN KESELAMATAN PASIEN

RUMAH SAKIT KARTINI RANGKASBITUNG

(LAPORAN INTERNAL)

RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAXIMAL 2X24 JAM

I. DATA PASIEN
Nama : ...............................................................................................................
Tanggal lahir (umur) : .................................................................... / .........................
No. Registrasi : ....................................................................
Jenis Kelamin : ( ) Laki-laki ( ) Perempuan
Penanggung Jawab Biaya : ( ) Pribadi ( ) Asuransi Swasta ( ) BPJS
Tanggal Masuk RS : ....................................................................
Ruang / Instalasi : ....................................................................
II. RINCIAN KEJADIAN
1. Tanggal dan waktu insiden
Tanggal : ..................................................................... Jam : ...........................................
2. Insiden :
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3. Kronologis Insiden
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4. Jenis insiden
Kejadian Nyaris Cidera / KNC (Near Miss)
Kejadian Tidak Cidera / KTC (No Harm)
Kejadian Tidak Diharapkan / KTD (Adverse Event)
Kejadian Sentinel (Sentinel Event)
Kejadian Potensial Cidera / KPC
5. Orang pertama yang melaporkan insiden
Karyawan : Dokter / Perawat / Bidan / Petugas lainnya, nama :
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Pasien, nama
................................................................................................................................................
Keluarga / Pendamping pasien, nama
.........................................................................................................
Pengunjung, nama
.......................................................................................................................................
Lainnya
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6. Insiden terjadi pada
Pasien
Lainnya .............................................................
Karyawan / Pengunjung / Pendamping / Keluarga Pasien
7. Insiden menyangkut pasien
Pasien Rawat Inap
Pasien Rawat Jalan
Pasien UGD
Lain-lain ..............................................................................
8. Tempat insiden
Lokasi kejadian .........................................................................................
(tempat pasien berada)
9. Insiden terjadi pada pasien : (sesuai kasus penyakit / spesialisasi)
Anak
ObGyn
Penyakit Dalam
Bedah Umum
Anestesi
Lainnya ....................................................
10. Unit / Departemen terkait yang menyebabkan insiden
Unit kerja penyebab ................................................................
11. Akibat Insiden terhadap pasien
Kematian
Cedera Irreversibel / cidera berat
Cidera reversibel / cidera Sedang
Cidera ringan
 Tidak ada cidera
12. Tindakan yang dilakukan segera setelah kejadian dan hasilnya :
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13. Tindakan dilakukan oleh :
Tim : terdiri dari
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Dokter
.......................................................................................................................................................
Perawat / Bidan
........................................................................................................................................
Petugas RS Lainnya
...................................................................................................................................
14. Apakah kejadian yang sama pernah terjadi di Unit Kerja lain ?
Ya Tidak
Apabila Ya, isi bagian ini.
Kapan ? ....................
Langkah dan tindakan apa yang telah diambil pada unit kerja tersbut untuk mencegah terulangnya
kejadian yang sama ?
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Pembuat Laporan : Penerima Laporan :

Paraf : Paraf :
Tanggal Lapor : Tanggal Terima :
 LEMBAR KERJA INVESTIGASI SEDERHANA

Penyebab Langsung Insiden

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Penyebab yang melatarbelakangi / akar masalah insiden :

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Tindakan yang sudah dilakukan Penanggung Tanggal

Jawab
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Tindakan yang akan dilakukan : Penanggung Tanggal

___________________________________________________ Jawab
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Kepala Unit / Kepala Ruang :

Nama : ___________________________________ Tanggal mulai investigasi :
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Tanda tangan : __________________________________ Tanggal selesai investigasi :
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Manajemen
Risiko Investigasi Lengkap : _______________ Ya/Tidak Tanggal :
(diisi Tim _________________________
PMKP-RS) Diperlukan investigasi lebih lanjut : Ya / Tidak