RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAKSIMAL 2X24 JAM

Formulir Laporan Insiden ke Tim KP di Metro Hospitals Cikupa

RINCIAN KEJADIAN
1. Tanggal .................................................dan Waktu Insiden................................................
2. Insiden : � Umum �Medis
3. Kronologis Insiden :
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026-001/MHCP/00/2020
 RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAKSIMAL 2X24 JAM
4. Jenis Insiden* :
� Kejadian Nyaris Cedera / KNC (Near miss)
� Kejadian Tidak diharapkan / KTD (Adverse Event) / Kejadian Sentinel
(Sentinel Event)
� Kejadian Tidak Cedera/KTC (No Harm)
� Kejadian Potensial Cedera/KPC (Reportable Circumstance)
5. Orang Pertama Yang Melaporkan Insiden*
� Karyawan : Dokter / Perawat / Petugas lainnya � Pasien � Pengunjung
� Keluarga /Pendamping pasien � Lain-lain ............................................(sebutkan)
6. Insiden terjadi pada* :
� Pasien � Lain-lain .................................................................................. (sebutkan)
7. DATA PASIEN
Nama : ................................................... No RM : .............................................
Umur *: � 0-1 bln � > 1 bln – 1 thn � > 1 thn – 5 thn � > 5 thn – 15 thn
� > 15 thn – 30 thn � > 30 thn – 65 thn� > 65 thn
Jenis kelamin : � Laki-laki � Perempuan
Penanggung biaya pasien : Pribadi � Asuransi Swasta � ASKES Pemerintah
� Perusahaan* � JAMKESMAS
Tanggal Masuk RS : ........................................................ Jam ......................................
8. Insiden terjadi pada pasien : (sesuai kasus penyakit / spesialisasi)
� Penyakit Dalam dan Subspesialisasinya � Anak dan Subspesialisasinya
� Bedah dan Subspesialisasinya � Obstetri Gynekologi dan Subspesialisasinya
� THT dan Subspesialisasinya � Mata dan Subspesialisasinya
� Saraf dan Subspesialisasinya � Anastesi dan Subspesialisasinya
� Kulit & Kelamin dan Subspesialisasinya � Jantung dan Subspesialisasinya
� Paru dan Subspesialisasinya � Jiwa dan Subspesialisasinya
� Lain-lain ................................................................................................................ (sebutkan)
9. Insiden menyangkut pasien :
� Pasien rawat inap � Pasien rawat jalan
� Pasien UGD � Lain-lain ............................................................. (sebutkan)
10. Tempat Insiden, Lokasi kejadian .............................................................................. (sebutkan)
11. Unit / Departemen terkait yang menyebabkan insiden
Unit kerja penyebab .................................................................................................... (sebutkan)
12. Akibat Insiden Terhadap Pasien* :
� Kematian � Cedera Irreversibel / Cedera Berat
� Cedera Reversibel / Cedera Sedang � Cedera Ringan � Tidak ada cedera
13. . Tindakan yang dilakukan segera setelah kejadian, dan hasilnya :
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026-001/MHCP/00/2020
 RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAKSIMAL 2X24 JAM
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Tindakan dilakukan oleh* :

� Tim : terdiri dari : ...........................................................................................................................
� Dokter � Perawat � Petugas lainnya ..........................................................................
14. Apakah kejadian yang sama pernah terjadi di Unit Kerja lain?*
� Ya � Tidak Apabila ya, isi bagian dibawah ini.
Kapan ? dan Langkah / tindakan apa yang telah diambil pada Unit kerja tersebut untuk mencegah
terulangnya kejadian yang sama?
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Pembuat Laporan Penerima lap 1( Ka Seksi)

Paraf Paraf
Tgl Lapor Tgl Terima
Penerima lap ke2 ( Ka Bagian) Penerima lap ke3(Q&R)
Paraf Paraf
Tgl Lapor Tgl Terima
Grading Resiko Kejadian *(Diisi oleh atasan pelapor) :
� BIRU � HIJAU � KUNING � MERAH
Grading Hijau & Biru dilanjutkan investigasi sederhana - Grading Kuning & Merah dilanjutkan dengan RCA
- Kejadian KTD laporkan 1x24 jam - Kejadian Sentinel langsung lapor ke Direktur
RISK GRADING MATRIX
PROBABILITAS /FREKUENSI / LIKELIHOOD
Level Frekuensi Kejadian actual
1 Sangat Jarang Dapat terjadi dalam lebih dari 5 tahun
2 Jarang Dapat terjadi dalam 2 – 5 tahun
3 Mungkin Dapat terjadi tiap 1 – 2 tahun
4 Sering Dapat terjadi beberapa kali dalam setahun
5 Sangat Sering Terjadi dalam minggu / bulan

DAMPAK KLINIS / CONSEQUENCES / SEVERITY

Level DESKRIPSI CONTOH DESKRIPSI

1 Insignificant Tidak ada cedera

2 Minor Cedera ringan Dapat diatasi dengan pertolongan pertama,
Cedera sedang
Berkurangnya fungsi motorik / sensorik / psikologis atau intelektual secara reversibel dan tidak berhubungan
3 Moderate dengan penyakit yang mendasarinya
Setiap kasus yang memperpanjang perawatan
Cedera luas / berat
4 Major Kehilangan fungsi utama permanent (motorik, sensorik, psikologis, intelektual) / irreversibel, tidak
berhubungan dengan penyakit yang mendasarinya
5 Cathastropic Kematian yang tidak berhubungan dengan perjalanan penyakit yang mendasarinya
RISK GRADING MATRIX
Potencial Concequences
Frekuensi/
Likelihood Insignificant Minor Moderate Major Catastropic
1 2 3 4 5
Sangat Sering Terjadi (Tiap mgg /bln)
5 Moderate Moderate High Extreme Extreme
Sering terjadi (Bebrp x /thn)
4 Moderate Moderate High Extreme Extreme
Mungkin terjadi (1-2 thn/x)
3 Low Moderate High Extreme Extreme
Jarang terjadi (2-5 thn/x)
2 Low Low Moderate High Extreme
Sangat jarang sekali (>5 thn/x)
1 Low Low Moderate High Extreme

Immediate review & action required at Board

Can be manage Clinical Manager / Lead Clinician Detailed review & urgent treatment level. Director must be informed
by procedure should assess the consequences againts should be undertaken by senior
cost of treating the risk management

026-001/MHCP/00/2020
RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAKSIMAL 2X24 JAM

026-001/MHCP/00/2020