RUMAH SAKIT UMUM YARSI PONTIANAK

KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN

TAHUN 2019

RUANGAN : Ranap Anak

BULAN : Jan 2019

NO VARIABEL
1 2 3 4 5 6 7
1 Kelengk JLH 2 4 4 10 3 2 3
apan + 2 4 4 10 3 2 3
pelaksan - 0 0 0 0 0 0 0
aan
2 Waktu JLH 0 0 0 0 0 0 0
Tunggu + 0 0 0 0 0 0 0
Hasil - 0 0 0 0 0 0 0
Pelayana
3 Waktu JLH 0 0 0 0 0 0 0
Tunggu + 0 0 0 0 0 0 0
Hasil - 0 0 0 0 0 0 0
Pelayana
4 Angka JLH 0 0 0 0 0 0 0
kepatuan + 0 0 0 0 0 0 0
pengisia - 0 0 0 0 0 0 0
n Daftar
5 Penulisa JLH 0 0 0 0 0 0 0
n Resep + 0 0 0 0 0 0 0
Obat - 0 0 0 0 0 0 0
tidak
6 Kesalaha JLH 0 0 0 0 0 0 0
n Penulis + 0 0 0 0 0 0 0
an Resep - 0 0 0 0 0 0 0
(Prescri
7 Evaluasi JLH 0 0 0 0 0 0 0
pelaksan + 0 0 0 0 0 0 0
aan - 0 0 0 0 0 0 0
Penatala
8 Monitori JLH 0 0 0 0 0 0 0
ng Reak + 0 0 0 0 0 0 0
si - 0 0 0 0 0 0 0
tranfusi
9 Ketepata JLH 0 0 0 0 0 0 0
n + 0 0 0 0 0 0 0
pengemb - 0 0 0 0 0 0 0
alian
10 Angka JLH 0 0 0 0 0 0 0
kejadian + 0 0 0 0 0 0 0
plebitis - 0 0 0 0 0 0 0
grII/Lebi
11 Pasien JLH 0 0 0 0 0 0 0
stroke + 0 0 0 0 0 0 0
ischemic
11

ischemic - 0 0 0 0 0 0 0
dan
12 Pasien JLH 0 0 0 0 0 0 0
dengan + 0 0 0 0 0 0 0
stroke - 0 0 0 0 0 0 0
iskemik
13 Aspirin JLH 0 0 0 0 0 0 0
diterima + 0 0 0 0 0 0 0
dalam - 0 0 0 0 0 0 0
waktu 24
14 Aspirin JLH 0 0 0 0 0 0 0
diresepk + 0 0 0 0 0 0 0
an untuk - 0 0 0 0 0 0 0
pasien
15 Persenta JLH 0 0 0 0 0 0 0
se + 0 0 0 0 0 0 0
tindakan - 0 0 0 0 0 0 0
Sectio
16 Jumlah JLH 0 0 0 0 0 0 0
kekoson + 0 0 0 0 0 0 0
gan stok - 0 0 0 0 0 0 0
obat
17 Insiden JLH 0 0 0 0 0 0 0
tertusuk + 0 0 0 0 0 0 0
jarum - 0 0 0 0 0 0 0
18 Penggun JLH 0 0 0 0 0 0 0
aan + 0 0 0 0 0 0 0
Ruang - 0 0 0 0 0 0 0
ICU
19 Demogra JLH 0 0 0 0 0 0 0
fi pasien Tj. Raya 0 0 0 0 0 0 0
yang Siantan 0 0 0 0 0 0 0
terdiagn
Tj. Hulu 0 0 0 0 0 0 0
osa Pre-
20 Kecepata JLH 0 0 0 0 0 0 0
n waktu + 0 0 0 0 0 0 0
pemberia - 0 0 0 0 0 0 0
n
21 Baku JLH 0 0 0 0 0 0 0
mutu + 0 0 0 0 0 0 0
limbah - 0 0 0 0 0 0 0
cair
22 Kepatuh JLH 2 4 4 10 3 2 3
an + 2 4 4 10 3 2 3
identifik - 0 0 0 0 0 0 0
asi
23 Kepatuh JLH 0 0 0 0 0 0 0
an + 0 0 0 0 0 0 0
penerapa - 0 0 0 0 0 0 0
n
24 Kepatuh JLH 0 0 0 0 0 0 0
an + 0 0 0 0 0 0 0
pemberia - 0 0 0 0 0 0 0
n label
25 Kepatuh JLH 0 0 0 0 0 0 0
an + 0 0 0 0 0 0 0
pelaksan
25

pelaksan - 0 0 0 0 0 0 0
aan
26 Persenta dokter 0 0 0 0 0 0 0
se lab 0 0 0 0 0 0 0
kepatuha apotik 0 0 0 0 0 0 0
n
radiologi
petugas 0 0 0 0 0 0 0
kesehata
27 Insiden JLH 0 0 0 0 0 0 0
pasien + 0 0 0 0 0 0 0
jatuh - 0 0 0 0 0 0 0
selama
28 Reaksi JLH 0 0 0 0 0 0 0
Obat + 0 0 0 0 0 0 0
Anastesi - 0 0 0 0 0 0 0
29 Kepuasa JLH
n pasien +
-
 SENSUS HARIAN MUTU DAN KESELAMATAN PASIEN

JUMLAH/TANGGAL
8 9 10 11 12 13 14 15 16 17
2 5 4 3 4 4 4 2 4 3
2 5 4 3 4 4 4 2 4 3
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 1 0 0
0 0 0 0 0 0 0 1 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0 1
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
2 5 4 3 4 4 4 2 4 3
2 5 4 3 4 4 4 2 4 3
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
AMATAN PASIEN

NGGAL
18 19 20 21 22 23 24 25 26 27
3 2 1 4 2 3 5 2 4 2
3 2 1 4 2 3 5 2 4 2
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 0
1 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
3 2 1 4 2 3 5 2 4 2
3 2 1 4 2 3 5 2 4 2
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0 2
0 0 0 0 0 1 0 0 0 2
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
28 29 30 31 TOTAL
5 0 4 2 102
5 0 4 2 102 100 standar capaian
0 0 0 0 0 Evaluasi p 100 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Monitoring Reaksi
100tranfusi 24
100jam pasca tranfusi
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Ketepatan >95 0
0 0 0 0 0 standar capaian
0 0 0 0 0 Angka kejadian plebitis
1.5 grII/Lebih
8.3 akibat perawatan d
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Pasien str 100 0
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Pasien den>90 0
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Aspirin di 100 0
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Aspirin dir 100 0
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Persentase<10 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Jumlah kek<2,5 99
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Insiden te 0 0
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Penggunaan 100 100
0 0 0 0 0
0 0 0 0 0 Sstandar capaian
0 0 0 0 0 #DIV/0! Tj. Raya 0 2
0 0 0 0 0 Siantan 0 1
0 0 0 0 0 TJ. Hulu 0 6
0 0 0 0 0 #DIV/0! standar capaian
0 0 1 0 3 Kecepatan 100 100
0 0 1 0 3
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Kepatuhan i 100 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Kepatuhan 100 100
0 0 0 0 0
0 0 0 0 0 standar capaian
0 0 0 0 0 Kepatuhan 100 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Kepatuhan 100 100
0 0 0 31 31 standar capaian
0 0 0 31 31 0 dokter >80 0
0 0 0 0 0 lab >80 0
0 0 0 0 0 apotik >80 0
0 0 0 0 0 radiologi >80 0
0 0 0 0 0 0 standar capaian
5 0 4 2 102 Insiden pa 0 100
5 0 4 2 102
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Reaksi Oba 100 0
0 0 0 0 0 standar capaian
0 0 0 0 0 Kepuasan p 80 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
 RUMAH SAKIT UMUM YARSI PONTIANAK
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN
TAHUN 2019

RUANGAN : Ranap Anak

BULAN : Feb 2019

NO VARIABEL
1 2 3 4 5 6 7
1 Kelengk JLH 2 3 5 4 0 8 5
apan + 2 3 5 4 0 8 5
pelaksan - 0 0 0 0 0 0 0
aan
2 Waktu JLH 0 0 0 0 0 0 0
Tunggu + 0 0 0 0 0 0 0
Hasil - 0 0 0 0 0 0 0
Pelayana
3 Waktu JLH 0 0 0 0 0 0 0
Tunggu + 0 0 0 0 0 0 0
Hasil - 0 0 0 0 0 0 0
Pelayana
4 Angka JLH 0 0 0 0 0 0 0
kepatuan + 0 0 0 0 0 0 0
pengisia - 0 0 0 0 0 0 0
n Daftar
5 Penulisa JLH 0 0 0 0 0 0 0
n Resep + 0 0 0 0 0 0 0
Obat - 0 0 0 0 0 0 0
tidak
6 Kesalaha JLH 0 0 0 0 0 0 0
n Penulis + 0 0 0 0 0 0 0
an Resep - 0 0 0 0 0 0 0
(Prescri
7 Evaluasi JLH 0 0 0 0 0 0 0
pelaksan + 0 0 0 0 0 0 0
aan - 0 0 0 0 0 0 0
Penatala
8 Monitori JLH 0 0 0 0 0 0 0
ng Reak + 0 0 0 0 0 0 0
si - 0 0 0 0 0 0 0
tranfusi
9 Ketepata JLH 0 0 0 0 0 0 0
n + 0 0 0 0 0 0 0
pengemb - 0 0 0 0 0 0 0
alian
10 Angka JLH 0 0 0 0 0 0 0
kejadian + 0 0 0 0 0 0 0
plebitis - 0 0 0 0 0 0 0
grII/Lebi
11 Pasien JLH 0 0 0 0 0 0 0
stroke + 0 0 0 0 0 0 0
ischemic
11

ischemic - 0 0 0 0 0 0 0
dan
12 Pasien JLH 0 0 0 0 0 0 0
dengan + 0 0 0 0 0 0 0
stroke - 0 0 0 0 0 0 0
iskemik
13 Aspirin JLH 0 0 0 0 0 0 0
diterima + 0 0 0 0 0 0 0
dalam - 0 0 0 0 0 0 0
waktu 24
14 Aspirin JLH 0 0 0 0 0 0 0
diresepk + 0 0 0 0 0 0 0
an untuk - 0 0 0 0 0 0 0
pasien
15 Persenta JLH 0 0 0 0 0 0 0
se + 0 0 0 0 0 0 0
tindakan - 0 0 0 0 0 0 0
Sectio
16 Jumlah JLH 0 0 0 0 0 0 0
kekoson + 0 0 0 0 0 0 0
gan stok - 0 0 0 0 0 0 0
obat
17 Insiden JLH 0 0 0 0 0 0 0
tertusuk + 0 0 0 0 0 0 0
jarum - 0 0 0 0 0 0 0
18 Penggun JLH 0 0 0 0 0 0 0
aan + 0 0 0 0 0 0 0
Ruang - 0 0 0 0 0 0 0
ICU
19 Demogra JLH 0 0 0 0 0 0 0
fi pasien Tj. Raya 0 0 0 0 0 0 0
yang Siantan 0 0 0 0 0 0 0
terdiagn
Tj. Hulu 0 0 0 0 0 0 0
osa Pre-
20 Kecepata JLH 0 0 0 0 0 0 0
n waktu + 0 0 0 0 0 0 0
pemberia - 0 0 0 0 0 0 0
n
21 Baku JLH 0 0 0 0 0 0 0
mutu + 0 0 0 0 0 0 0
limbah - 0 0 0 0 0 0 0
cair
22 Kepatuh JLH 2 3 5 4 0 8 5
an + 2 3 5 4 0 8 5
identifik - 0 0 0 0 0 0 0
asi
23 Kepatuh JLH 0 0 0 0 0 0 0
an + 0 0 0 0 0 0 0
penerapa - 0 0 0 0 0 0 0
n
24 Kepatuh JLH 0 0 0 0 0 0 0
an + 0 0 0 0 0 0 0
pemberia - 0 0 0 0 0 0 0
n label
25 Kepatuh JLH 0 0 0 0 0 0 0
an + 0 0 0 0 0 0 0
pelaksan
25

pelaksan - 0 0 0 0 0 0 0
aan
26 Persenta dokter 0 0 0 0 0 0 0
se lab 0 0 0 0 0 0 0
kepatuha apotik 0 0 0 0 0 0 0
n
radiologi
petugas 0 0 0 0 0 0 0
kesehata
27 Insiden JLH 0 0 0 0 0 0 0
pasien + 0 0 0 0 0 0 0
jatuh - 0 0 0 0 0 0 0
selama
28 Reaksi JLH 0 0 0 0 0 0 0
Obat + 0 0 0 0 0 0 0
Anastesi - 0 0 0 0 0 0 0
29 Kepuasa JLH
n pasien +
-
 SENSUS HARIAN MUTU DAN KESELAMATAN PASIEN

JUMLAH/TANGGAL
8 9 10 11 12 13 14 15 16 17
3 3 2 6 7 4 1 0 5 3
3 3 2 6 7 4 1 0 5 3
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
3 3 2 6 7 4 1 0 5 3
3 3 2 6 7 4 1 0 5 3
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
AMATAN PASIEN

NGGAL
18 19 20 21 22 23 24 25 26 27
8 5 3 5 1 3 1 3 5 3
8 5 3 5 1 3 1 3 5 3
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
8 5 3 5 1 3 1 3 5 3
8 5 3 5 1 3 1 3 5 3
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
28 29 30 31 TOTAL
5 0 0 0 103
5 0 0 0 103 100 standar capaian
0 0 0 0 0 Evaluasi p 100 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Monitoring Reaksi
100tranfusi 24
100jam pasca tranfusi
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Ketepatan >95 0
0 0 0 0 0 standar capaian
0 0 0 0 0 Angka kejadian plebitis
1.5 grII/Lebih
8.3 akibat perawatan d
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Pasien str 100 0
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Pasien den>90 0
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Aspirin di 100 0
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Aspirin dir 100 0
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Persentase<10 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Jumlah kek<2,5 99
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Insiden te 0 0
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Penggunaan 100 100
0 0 0 0 0
0 0 0 0 0 Sstandar capaian
0 0 0 0 0 #DIV/0! Tj. Raya 0 2
0 0 0 0 0 Siantan 0 1
0 0 0 0 0 TJ. Hulu 0 6
0 0 0 0 0 #DIV/0! standar capaian
0 0 1 0 1 Kecepatan 100 100
0 0 1 0 1
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Kepatuhan i 100 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Kepatuhan 100 100
0 0 0 0 0
0 0 0 0 0 standar capaian
0 0 0 0 0 Kepatuhan 100 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Kepatuhan 100 100
0 0 0 33 33 standar capaian
0 0 0 33 33 0 dokter >80 0
0 0 0 0 0 lab >80 0
0 0 0 0 0 apotik >80 0
0 0 0 0 0 radiologi >80 0
0 0 0 0 0 0 standar capaian
5 0 0 0 103 Insiden pa 0 100
5 0 0 0 103
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Reaksi Oba 100 0
0 0 0 0 0 standar capaian
0 0 0 0 0 Kepuasan p 80 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
 RUMAH SAKIT UMUM YARSI PONTIANAK
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN
TAHUN 2019

RUANGAN : Ranap Anak

BULAN : maret 2019

NO VARIABEL
1 2 3 4 5 6 7
1 Kelengk JLH 4 9 5 2 3 2 5
apan + 4 9 5 2 3 2 5
pelaksan - 0 0 0 0 0 0 0
aan
2 Waktu JLH 0 0 0 0 0 0 0
Tunggu + 0 0 0 0 0 0 0
Hasil - 0 0 0 0 0 0 0
Pelayana
3 Waktu JLH 0 0 0 0 0 0 0
Tunggu + 0 0 0 0 0 0 0
Hasil - 0 0 0 0 0 0 0
Pelayana
4 Angka JLH 0 0 0 0 0 0 0
kepatuan + 0 0 0 0 0 0 0
pengisia - 0 0 0 0 0 0 0
n Daftar
5 Penulisa JLH 0 0 0 0 0 0 0
n Resep + 0 0 0 0 0 0 0
Obat - 0 0 0 0 0 0 0
tidak
6 Kesalaha JLH 0 0 0 0 0 0 0
n Penulis + 0 0 0 0 0 0 0
an Resep - 0 0 0 0 0 0 0
(Prescri
7 Evaluasi JLH 0 0 0 0 0 0 0
pelaksan + 0 0 0 0 0 0 0
aan - 0 0 0 0 0 0 0
Penatala
8 Monitori JLH 0 0 0 0 0 0 0
ng Reak + 0 0 0 0 0 0 0
si - 0 0 0 0 0 0 0
tranfusi
9 Ketepata JLH 0 0 0 0 0 0 0
n + 0 0 0 0 0 0 0
pengemb - 0 0 0 0 0 0 0
alian
10 Angka JLH 0 0 0 0 0 0 0
kejadian + 0 0 0 0 0 0 0
plebitis - 0 0 0 0 0 0 0
grII/Lebi
11 Pasien JLH 0 0 0 0 0 0 0
stroke + 0 0 0 0 0 0 0
ischemic - 0 0 0 0 0 0 0
dan
12 Pasien JLH 0 0 0 0 0 0 0
dengan + 0 0 0 0 0 0 0
stroke - 0 0 0 0 0 0 0
iskemik
13 Aspirin JLH 0 0 0 0 0 0 0
diterima + 0 0 0 0 0 0 0
dalam - 0 0 0 0 0 0 0
waktu 24
14 Aspirin JLH 0 0 0 0 0 0 0
diresepk + 0 0 0 0 0 0 0
an untuk - 0 0 0 0 0 0 0
pasien
15 Persenta JLH 0 0 0 0 0 0 0
se + 0 0 0 0 0 0 0
tindakan - 0 0 0 0 0 0 0
Sectio
16 Jumlah JLH 0 0 0 0 0 0 0
kekoson + 0 0 0 0 0 0 0
gan stok - 0 0 0 0 0 0 0
obat
17 Insiden JLH 0 0 0 0 0 0 0
tertusuk + 0 0 0 0 0 0 0
jarum - 0 0 0 0 0 0 0
18 Penggun JLH 0 0 0 0 0 0 0
aan + 0 0 0 0 0 0 0
Ruang - 0 0 0 0 0 0 0
ICU
19 Demogra JLH 0 0 0 0 0 0 0
fi pasien Tj. Raya 0 0 0 0 0 0 0
yang Siantan 0 0 0 0 0 0 0
terdiagn
Tj. Hulu 0 0 0 0 0 0 0
osa Pre-
20 Kecepata JLH 0 0 0 0 0 0 0
n waktu + 0 0 0 0 0 0 0
pemberia - 0 0 0 0 0 0 0
n
21 Baku JLH 0 0 0 0 0 0 0
mutu + 0 0 0 0 0 0 0
limbah - 0 0 0 0 0 0 0
cair
22 Kepatuh JLH 4 9 5 2 3 2 5
an + 4 9 5 2 3 2 5
identifik - 0 0 0 0 0 0 0
asi
23 Kepatuh JLH 0 0 0 0 0 0 0
an + 0 0 0 0 0 0 0
penerapa - 0 0 0 0 0 0 0
n
24 Kepatuh JLH 0 0 0 0 0 0 0
an + 0 0 0 0 0 0 0
pemberia - 0 0 0 0 0 0 0
n label
25 Kepatuh JLH 0 0 0 0 0 0 0
an + 0 0 0 0 0 0 0
pelaksan - 0 0 0 0 0 0 0
aan
26 Persenta dokter 0 0 0 0 0 0 0
se lab 0 0 0 0 0 0 0
kepatuha apotik 0 0 0 0 0 0 0
n
radiologi
petugas 0 0 0 0 0 0 0
kesehata
27 Insiden JLH 0 0 0 0 0 0 0
pasien + 0 0 0 0 0 0 0
jatuh - 0 0 0 0 0 0 0
selama
28 Reaksi JLH 0 0 0 0 0 0 0
Obat + 0 0 0 0 0 0 0
Anastesi - 0 0 0 0 0 0 0
29 Kepuasa JLH
n pasien +
-
 SENSUS HARIAN MUTU DAN KESELAMATAN PASIEN

JUMLAH/TANGGAL
8 9 10 11 12 13 14 15 16 17
5 5 2 5 7 5 3 3 5 5
5 5 2 5 7 5 3 3 5 5
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
5 5 2 5 7 5 3 3 5 5
5 5 2 5 7 5 3 3 5 5
0 0 0 0 0 0 0 0 0 0
3 0 0 0 2 0 0 0 0 0
3 0 0 0 2 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
AMATAN PASIEN

NGGAL
18 19 20 21 22 23 24 25 26 27
5 3 7 7 8 4 7 8 5 5
5 3 7 7 8 4 7 8 5 5
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
5 3 7 7 8 4 7 8 5 5
5 3 7 7 8 4 7 8 5 5
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
28 29 30 31 TOTAL
2 4 5 3 148
2 4 5 3 148 100 standar capaian
0 0 0 0 0 Evaluasi p 100 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Monitoring Reaksi
100tranfusi 24
100jam pasca tranfusi
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Ketepatan >95 0
0 0 0 0 0 standar capaian
0 0 0 0 0 Angka kejadian plebitis
1.5 grII/Lebih
8.3 akibat perawatan d
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Pasien str 100 0
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Pasien den>90 0
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Aspirin di 100 0
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Aspirin dir 100 0
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Persentase<10 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Jumlah kek<2,5 99
0 0 0 0 0
0 0 0 0 0 0 standar capaian
0 0 0 0 0 Insiden te 0 0
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Penggunaan 100 100
0 0 0 0 0
0 0 0 0 0 Sstandar capaian
0 0 0 0 0 #DIV/0! Tj. Raya 0 2
0 0 0 0 0 Siantan 0 1
0 0 0 0 0 TJ. Hulu 0 6
0 0 0 0 0 #DIV/0! standar capaian
0 0 1 0 1 Kecepatan 100 100
0 0 1 0 1
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Kepatuhan i 100 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Kepatuhan 100 100
0 0 0 0 0
0 0 0 0 0 standar capaian
0 0 0 0 0 Kepatuhan 100 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar capaian
0 0 0 0 0 Kepatuhan 100 100
0 0 0 41 41 standar capaian
0 0 0 41 41 0 dokter >80 0
0 0 0 0 0 lab >80 0
0 0 0 0 0 apotik >80 0
0 0 0 0 0 radiologi >80 0
0 0 0 0 0 0 standar capaian
2 4 5 3 148 Insiden pa 0 100
2 4 5 3 148
0 0 0 0 0 0 standar capaian
0 0 0 0 5 Reaksi Oba 100 0
0 0 0 0 5 standar capaian
0 0 0 0 0 Kepuasan p 80 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
 RUMAH SAKIT UMUM YARSI PONTIANAK
KOMITE PENINGKATAN MUTU DAN KESELAMATAN PASIEN
TAHUN 2019

RUANGAN : Ranap Anak

BULAN : april 2019

NO VARIABEL
1 2 3 4 5 6 7
1 Kelengk JLH 4 4 3 2 5 5 1
apan + 4 4 3 2 5 5 1
pelaksan - 0 0 0 0 0 0 0
aan
2 Waktu JLH 0 0 0 0 0 0 0
Tunggu + 0 0 0 0 0 0 0
Hasil - 0 0 0 0 0 0 0
Pelayana
3 Waktu JLH 0 0 0 0 0 0 0
Tunggu + 0 0 0 0 0 0 0
Hasil - 0 0 0 0 0 0 0
Pelayana
4 Angka JLH 0 0 0 0 0 0 0
kepatuan + 0 0 0 0 0 0 0
pengisia - 0 0 0 0 0 0 0
n Daftar
5 Penulisa JLH 0 0 0 0 0 0 0
n Resep + 0 0 0 0 0 0 0
Obat - 0 0 0 0 0 0 0
tidak
6 Kesalaha JLH 0 0 0 0 0 0 0
n Penulis + 0 0 0 0 0 0 0
an Resep - 0 0 0 0 0 0 0
(Prescri
7 Evaluasi JLH 0 0 0 0 0 0 0
pelaksan + 0 0 0 0 0 0 0
aan - 0 0 0 0 0 0 0
Penatala
8 Monitori JLH 0 0 0 0 0 0 0
ng Reak + 0 0 0 0 0 0 0
si - 0 0 0 0 0 0 0
tranfusi
9 Ketepata JLH 0 0 0 0 0 0 0
n + 0 0 0 0 0 0 0
pengemb - 0 0 0 0 0 0 0
alian
10 Angka JLH 0 0 0 0 0 0 0
kejadian + 0 0 0 0 0 0 0
plebitis - 0 0 0 0 0 0 0
grII/Lebi
11 Pasien JLH 0 0 0 0 0 0 0
stroke + 0 0 0 0 0 0 0
ischemic - 0 0 0 0 0 0 0
dan
12 Pasien JLH 0 0 0 0 0 0 0
dengan + 0 0 0 0 0 0 0
stroke - 0 0 0 0 0 0 0
iskemik
13 Aspirin JLH 0 0 0 0 0 0 0
diterima + 0 0 0 0 0 0 0
dalam - 0 0 0 0 0 0 0
waktu 24
14 Aspirin JLH 0 0 0 0 0 0 0
diresepk + 0 0 0 0 0 0 0
an untuk - 0 0 0 0 0 0 0
pasien
15 Persenta JLH 0 0 0 0 0 0 0
se + 0 0 0 0 0 0 0
tindakan - 0 0 0 0 0 0 0
Sectio
16 Jumlah JLH 0 0 0 0 0 0 0
kekoson + 0 0 0 0 0 0 0
gan stok - 0 0 0 0 0 0 0
obat
17 Insiden JLH 0 0 0 0 0 0 0
tertusuk + 0 0 0 0 0 0 0
jarum - 0 0 0 0 0 0 0
18 Penggun JLH 0 0 0 0 0 0 0
aan + 0 0 0 0 0 0 0
Ruang - 0 0 0 0 0 0 0
ICU
19 Demogra JLH 0 0 0 0 0 0 0
fi pasien Tj. Raya 0 0 0 0 0 0 0
yang Siantan 0 0 0 0 0 0 0
terdiagn
Tj. Hulu 0 0 0 0 0 0 0
osa Pre-
20 Kecepata JLH 0 0 0 0 0 0 0
n waktu + 0 0 0 0 0 0 0
pemberia - 0 0 0 0 0 0 0
n
21 Baku JLH 0 0 0 0 0 0 0
mutu + 0 0 0 0 0 0 0
limbah - 0 0 0 0 0 0 0
cair
22 Kepatuh JLH 4 4 3 2 5 5 1
an + 4 4 3 2 5 5 1
identifik - 0 0 0 0 0 0 0
asi
23 Kepatuh JLH 0 0 0 0 0 0 0
an + 0 0 0 0 0 0 0
penerapa - 0 0 0 0 0 0 0
n
24 Kepatuh JLH 0 0 0 0 0 0 0
an + 0 0 0 0 0 0 0
pemberia - 0 0 0 0 0 0 0
n label
25 Kepatuh JLH 0 0 0 0 0 0 0
an + 0 0 0 0 0 0 0
pelaksan - 0 0 0 0 0 0 0
aan
26 Persenta dokter 0 0 0 0 0 0 0
se lab 0 0 0 0 0 0 0
kepatuha apotik 0 0 0 0 0 0 0
n
radiologi
petugas 0 0 0 0 0 0 0
kesehata
27 Insiden JLH 0 0 0 0 0 0 0
pasien + 0 0 0 0 0 0 0
jatuh - 0 0 0 0 0 0 0
selama
28 Reaksi JLH 0 0 0 0 0 0 0
Obat + 0 0 0 0 0 0 0
Anastesi - 0 0 0 0 0 0 0
29 Kepuasa JLH
n pasien +
-
 SENSUS HARIAN MUTU DAN KESELAMATAN PASIEN

JUMLAH/TANGGAL
8 9 10 11 12 13 14 15 16 17
2 2 2 2 5 4 4 6 1 2
2 2 2 2 5 4 4 6 1 2
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
2 2 2 2 5 4 4 6 1 2
2 2 2 2 5 4 4 6 1 2
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0 0
0 0 0 0 0 1 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
AMATAN PASIEN

NGGAL
18 19 20 21 22 23 24 25 26 27
5 3 2 6 2 0 4 1 1 5
5 3 2 6 2 0 4 1 1 5
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 1 0 0 0 0
0 0 0 0 0 1 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
5 3 2 6 2 0 4 1 1 5
5 3 2 6 2 0 4 1 1 5
0 0 0 0 0 0 0 0 0 0
1 0 0 0 0 2 0 0 0 0
1 0 0 0 0 2 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0 0 0
28 29 30 31 TOTAL
2 2 3 0 90
2 2 3 0 90 100 standar
0 0 0 0 0 Evaluasi p 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar
0 0 0 0 0 Monitoring Reaksi
100tranfusi 24 jam pasca tranfusi
0 0 0 0 0
0 0 0 0 0 0 standar
0 0 0 0 0 Ketepatan >95
0 0 0 0 0 standar
0 0 0 0 0 Angka kejadian plebitis
1.5 grII/Lebih akibat perawatan d
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 0 standar
0 0 0 0 0 Pasien str 100
0 0 0 0 0
0 0 0 0 0 0 standar
0 0 0 0 0 Pasien den>90
0 0 0 0 0
0 0 0 0 0 0 standar
0 0 0 0 0 Aspirin di 100
0 0 0 0 1
0 0 0 0 1 0 standar
0 0 0 0 0 Aspirin dir 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar
0 0 0 0 0 Persentase<10
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar
0 0 0 0 0 Jumlah kek<2,5
0 0 0 0 0
0 0 0 0 0 0 standar
0 0 0 0 0 Insiden te 0
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar
0 0 0 0 0 Penggunaan 100
0 0 0 0 0
0 0 0 0 0 Sstandar
0 0 0 0 0 #DIV/0! Tj. Raya 0
0 0 0 0 0 Siantan 0
0 0 0 0 0 TJ. Hulu 0
0 0 0 0 0 #DIV/0! standar
0 0 0 0 0 Kecepatan 100
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar
0 0 0 0 0 Kepatuhan i 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar
0 0 0 0 0 Kepatuhan 100
0 0 0 0 0
0 0 0 0 0 standar
0 0 0 0 0 Kepatuhan 100
0 0 0 0 0
0 0 0 0 0 #DIV/0! standar
0 0 0 0 0 Kepatuhan 100
0 0 0 23 23 standar
0 0 0 23 23 0 dokter >80
0 0 0 0 0 lab >80
0 0 0 0 0 apotik >80
0 0 0 0 0 radiologi >80
0 0 0 0 0 0 standar
2 2 3 0 90 Insiden pa 0
2 2 3 0 90
0 0 0 0 0 0 standar
0 0 0 0 4 Reaksi Oba 100
0 0 0 0 4 standar
0 0 0 0 0 Kepuasan p 80
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0
0 0 0 0 0