2. KPC : ..........................................................................................................................................
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3. Orang Pertama Yang Melaporkan Insiden*
Karyawan : Dokter / Perawat / Petugas lainnya
Pasien
Keluarga / Pendamping pasien
Pengunjung
Lain-lain ...........................................................................................(sebutkan)
6. Tindakan apa yang dilakukan untuk mengatasi kondisi potensi cedera selama ini ?
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