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RISK  MANAGEMENT  

Dr ARJATY W DAUD MARS

Arjaty  Daud/  IMRK/  Risk  Management   7/26/14  

What ?

RISIKO ADALAH :

“ POTENSI TERJADINYA KERUGIAN YANG DAPAT TIMBUL DARI

PROSES KEGIATAN SAAT INI ATAU KEJADIAN DIMASA DATANG.”

ERM, Risk Management Handbook for Health Care Organization

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RISIKO  DI  RUMAH  SAKIT    

Arjaty  Daud/  IMRK/  Risk  Management   7/26/14  

   
Ò   RISIKO  KLINIS  /  Clinical  Risk  :  

 Semua  isu  yang  dapat  berdampak  terhadap  

pencapaian  pelayanan  pasien  yang  bermutu  
tinggi,  aman  dan  efektif.  

Ò   RISIKO  NONKLINIS/  Corporate  Risk  :  

 Semua  issu  yang  dapat  berdampak  terhadap  
tercapainya  tugas  pokok  dan  kewajiban  
hukum  dari  rumah  sakit  sebagai  korporasi.  

Arjaty  Daud/  IMRK/  Risk  Management   7/26/14  

KATEGORI RISIKO DI RUMAH SAKIT :

( CATEGORIES OF RISK )

Ø  Patient care-related risks

Ø  Medical staff-related risks

Ø  Employee-related risks

Ø  Property-related risks

Ø  Financial risks

Ø  Other risks

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RISK VS. MEDICAL ERROR

Potential Failure Actual Failure

Risks   Medical  
Errors  

What could go wrong What is going wrong

With this process? With this process?

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Actual SE
Examples
SE Patient death from medication
Policy misadministration
"reviewable"
Incident report

Significant
misadministration
Adverse events -- patient survives
"Important single events"

Full range of
Majority of
Near Miss events, medication
errors

High Risk
Processes

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Pasien
Near Miss
tidak terpapar
(KNC=Kejadian NYARIS CIDERA)
- ERROR, diket, dibatalkan (prevention)

Medical Error
Tidak No Harm Event
Procces of care error cidera

(KTC=Kejadian TIDAK CIDERA)

Kesalahan proses yg
dpt dicegah :
•  Error in planning
•  Error in Execution
- Dpt obat “c.i.”, tdk timbul (chance)
- Dpt obat “c.i.”, diket, beri anti-nya
Pasien (mitigation)

terpapar Pasien
Krn berbuat : commission cidera Adverse Event
Krn tidak berbuat : omission
(KTD=Kejadian Tdk Diharapkan)
Dpt dicegah

significant
potential for harm Tidak reportable
situation cidera circumstance

(KPC=Kondisi Potensi Cedera)

Proses of Care
Non Error

Pasien Pasien Adverse Event

terpapar cidera

(KTD=Kejadian Tdk Diharapkan)

-TIDAK Dpt dicegah

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JENIIS INSIDEN YG HARUS

DILAPORKAN

1.  KEJADIAN SENTINEL

2. KEJADIAN TIDAK DIHARAPKAN (KTD)
Insiden yang mengakibatkan cedera pada pasien
3. KEJADIAN TIDAK CEDERA (KTC)
Insiden yang sudah terpapar kepada pasien tapi tidak
menimbulkan cedera
4. KEJADIAN NYARIS CEDERA (KNC)
Insiden yang belum terpapar kepada pasien

KONDISI POTENSIAL RISIKO / CEDERA YANG HARUS DILAPORKAN

KONDISI POTENSIAL CEDERA (KPC)

Kondisi yang berpotensial menimbulkan cedera tapi belum terjadi insiden

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JCI Sentinel Event Policy

Sentinel Events

•  JCI reviews organization activities in response to sentinel events in its

accreditation process.

•  This includes all initial accreditation surveys, triennial accreditation

surveys, and, as appropriate, focused surveys.

The following apply:

A sentinel event is an unanticipated occurrence involving death or major
•  permanent loss of function unrelated to the natural course of the patient’s
illness or underlying condition.
•  Such events are called sentinel because they signal a need for immediate
investigation and response.
•  The terms sentinel event and medical error are not synonymous; not all
sentinel events occur because of an error, and not all errors result in
sentinel events.

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QPS 6 JCI Sentinel Event Policy

The following sentinel events are subject to review by JCI and include
any occurrence that meets the following criteria:
The event has resulted in an unanticipated death unrelated to
•  the natural course of the patient’s illness or underlying
condition (for example, suicide).
•  The event has resulted in major permanent loss of function
unrelated to the natural course of the patient’s illness or
underlying condition.
•  The event resulted from wrong-site, wrong-patient, wrong-
procedure surgery.
•  The event has resulted in an infant abduction or infant who
was sent home with the wrong parents.

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SENTINEL EVENT QPS 7 (JCI 5TH EDITION)

1. an unanticipated
Death that is
death, including, but not limited to,
unrelated to the natural course of the patient’s illness or
• 
underlying condition (for example, death from a post operative
infection or a hospital-acquired pulmonary embolism);
•  Death of a full-terminfant ;and
•  suicide;
2. of
Major permanent loss off unction unrelated to the patient’s natural course
illness or underlying condition;
3.  wrong-site, wrong-procedure, wrong-patient surgery;

4. Transmission of a chronic or fatal disease or illnessas as a result of

blood or blood products or transplanting contaminated organs or tissues;
5.  infant abduction or an infant sent home with the wrong parents; and
rape, workplace violence such as assault (leading to death or
permanent loss of function); or homicide (willful killing) of a patient,
staff member, practitioner, medical student, trainee, visitor, or vendor
while on hospital property. (Also see SQE.8.2)

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HOW ?

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MANAJEMEN  RISIKO  RUMAH  SAKIT  

• Kegiatan berupa identifikasi dan evaluasi

untuk mengurangi risiko cedera dan kerugian
pada pasien, karyawan rumah sakit, pengunjung
dan organisasinya sendiri (The Joint Commission on Accreditation of
Healthcare Organizations / JCAHO).

•  Kegiatan meminimalkan bahaya terhadap

pasien, kegiatan untuk menciptakan
lingkungan yang aman bagi karyawan, pasien
dan pengunjung (ASHRM)

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Patient care
Related Medical Staff
Risks Related Risks

Hosp
Other Risk Employee
Risks Mgt Related
Risks

Financial Property
Risks Related
Risks

Roberta Caroll, editor : Risk Management Handbook for Health

Care Organizations, 4th edition, Jossey Bass, 2004

Arjaty  Daud/  IMRK/  Risk  Management   7/26/14  

PROSES MANAJEMEN RISIKO

TEGAKKAN KONTEKS
(Rencana Strategis)

IDENTIFIKASI RISIKO
KOMUNIKASI DAN KONSULTASI

Reaktif & Proaktif)

MONITOR DAN REVIEW

ANALISA RISIKO
(Risk Grading, RCA, FMEA)

ASESMEN RISIKO

EVALUASI RISIKO
(CBA)

KELOLA RISIKO
(Kontrol,, Transfer,
RISK REGISTER

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 IDENTIFIKASI  RISIKO  

n Incident reporting (Laporan Insiden)

Reaktif
n  Case Report
n  Complaint
n  Claim data
n  Clinical care review
n  Audit Medis
Proaktif
n  Occurrence Screening /
Medical Record Review
n  Survey / Self Assesment

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ANALISA RISIKO

RISK ASSESSMENT TOOLS

Dalam Proses manajemen risiko terdapat
beberapa tools yang digunakan untuk analisa
risiko yaitu :
É  Risk Matrix Grading
É  Root Cause Analysis (RCA)

É  Failure Mode Effect Analysis (FMEA)

É  Hazard Vulnerability Assessment (HVA)

É  Infection Control Risk assessment (ICRA)

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RISK MATRIX

“RISIKO SEBAGAI SUATU FUNGSI DARI PROBABILITAS (CHANCE,LIKELIHOOD) DARI

SUATU KEJADIAN YANG TIDAK DIINGINKAN,DAN TINGKAT KEPARAHAN ATAU
BESARNYA DAMPAK DARI KEJADIAN TERSEBUT.”
Skor risiko : Probability X Consequence
Dampak (Consequences)
Penilaian dampak / akibat suatu insiden adalah seberapa berat akibat
yang dialami pasien mulai dari tidak ada cedera sampai meninggal
Probabilitas / Frekuensi / /Likelihood
Penilaian tingkat probabilitas / frekuensi risiko adalah seberapa seringnya
insiden tersebut terjadi

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RISK MATRIX GRADING

PROBABILITAS /FREKUENSI / LIKELIHOOD

Level Frekuensi Kejadian aktual

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

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DAMPAK KLINIS / CONSEQUENCES / SEVERITY

Level DESKRIPSI CONTOH DESKRIPSI
1 Insignificant Tidak ada cedera, kerugian keuangan kecil

2 Minor • Dapat diatasi dengan pertolongan pertama,

• kerugian keuangan sedang

3 Moderate • Berkurangnya fungsi motorik / sensorik /

4 Major
5 Cathastropic
psikologis atau intelektual secara
semipermanent / reversibel / tidak
berhubungan dengan penyakit
• S e t i a p k a s u s y a n g m e m p e r p a n j a n g
perawatan
• Cedera luas
• K ehilangan fungsi utama permanent
(motorik, sensorik, psikologis,
intelektual), permanen / irreversibel/ tidak
berhubungan dengan penyakit
• Kerugian keuangan besar
• Kematian yang tidak berhubungan dengan
perjalanan penyakit.
• Kerugian keuangan sangat besar.

RISK GRADING MATRIX

Potencial Concequences
Frekuensi/ Insignificant Minor Moderate Major Catastropic
Likelihood
1 2 3 4 5

Sangat Sering Terjadi Moderate Moderate High Extreme Extreme

(Tiap mgg /bln)
5
Sering terjadi Moderate Moderate High Extreme Extreme
(Bebrp x /thn)
4
Mungkin terjadi Low Moderate High Extreme Extreme
(1-2 thn/x)
3
Jarang terjadi Low Low Moderate High Extreme
(2-5 thn/x)
2
Sangat jarang sekali (>5 Low Low Moderate High Extreme
thn/x)
1

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

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RISK MAPPING
IMPACT VS. PROBABILITY
High Medium Risk High Risk

I
M Share Mitigate & Control
P
A Low Risk Medium Risk
C
T
Accept Control

Low PROBABILITY High

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SKOR
Arjaty  DAMPAK
Daud/  IMRK/  Risk  Management   7/26/14  

1 2 3 4 5
INSGNIFICANT MINOR MODERATE MAJOR CATASTROPHIC

CIDERA Tidak ada cedera Dapat diatasi • B e r k u r a n g n y a • Cedera luas

PASIEN fungsi motorik /
Kematian
dengan • K e h i l a n g a n
sensorik
pertolongan fungsi utama
• Setiap kasus yang
pertama memperpanjang permanent
perawatan
PELAYANAN/ TERHENTI LEBIH TERHENTI LEBIH TERHENTI TERHENTI LEBIH TERHENTI
OPERASIO DARI 1 JAM DARI 8 JAM LEBIH DARI 1 DARI 1 MINGGU PERMANEN
NAL HARI

BIAYA / KERUGIAN KECIL KERUGIAN LEBIH KERUGIAN LEBIH KERUGIAN LEBIH KERUGIAN LEBIH
KEUANGAN DARI 0,1% DARI 0,25 % DARI 0,5% DARI 1%
ANGGARAN ANGGARAN ANGGARAN ANGGARAN

PUBLIKASI RUMOR - MEDIA LOKAL -  MEDIA LOKAL MEDIA MEDIA NASIONAL

- WAKTU -  WAKTU LAMA NASIONAL LEBIH DARI 3 HARI
SINGKAT KURANG DARI 3
HARI

REPUTASI RUMOR DAMPAK KECIL DAMPAK DAMPAK SERIUS MENJADI

THD MORIL BERMAKNA THD THD MORIL MASALAH
KARYAWAN DAN MORIL KARYAWAN KARYAWAN DAN
BERAT BAGI PR
KEPERCAYAAN DAN KEPERCAYAAN
MASYARAKAT KEPERCAYAAN MASYARAKAT
MASYARAKAT 24  

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EVALUASI RISIKO

1.  Risk Ranking

2.  Prioritize the risk

3.  Cost Benefit Analysis (setelah diranking,
biaya unt mengurangi resiko dibandingkan
dengan biaya kalau terjadi resiko)

4.  Determine is the risk to be accepted or not

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PENGELOLAAN RISIKO  
q  Dihindari (Avoid)
tidak melaksanakan kegiatan yang menimbulkan risiko

q  Direduksi (Reduction)

mengurangi atau mengandalikan dampak yang mungkin terjadi

q  Dipindahkan (Transfer)

mengatur agar pihak lain ikut menanggung atau
berbagi sebagian risiko, melalui kontrak,kerjasama, joint venture

q  Diterima: (Accept)

beberapa risiko sangat ringan sehingga dapat diterima /
dikelola sendiri

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RISK REGISTER

Ò  RS membuat Rekapitulasi risiko Tahunan à Risk

Register
Ò  Risk Register :
1.  Risiko yg teridentifikasi dalam 1 tahun
2.  Informasi Insiden keselamatan pasien, klaim litigasi dan
komplain, investigasi eksternal & internal, exernal
assessments

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Arjaty Daud, IMRK 28

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RISK  REGISTER  
RISK REGISTER
TAHUN …..

EVALU
ANALISIS
IDENTIFIKASI RISIKO ASI
RISIKO
RISIKO
Sumber Insiden/
No Lok Akar Efek /
identifika Kejadia
. asi Masalah Dampak
Keteg si n
ori 1. Jenis Tipe

PRIORITAS RISIKO
Risiko Laporan Insiden Insid PENGELOL
Risk

Probabilitas
Risk Score
mis. Insiden en AAN

Dampak
Owner / PIC
Kes 2. RISIKO
Pasien Komplain ( Mengapa
/ K3 / 3. Litigasi Hal itu bisa
Inf 4. Rapat terjadi )
Contr Unit
ol dll) Kerja
5. Survey
6. Ronde

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RISK MANAGEMENT STEPS

T IF
AK
O
PR
1.  Understand Risk àEstablish Risk Management Program
2.  Identify High Risk Processes (Get input from
stakeholders)
3.  Conduct a Risk Assessment
4.  Conduct Proactive Risk Analysis
5.  Develop Mitigating Strategies
6.  Develop Contingency Plans
7.  Implement Strategies and Plans
8.  Reassess Risks

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IDENTIFY AND REDUCE

Risk Management
UNANTICIPATED ADVERSE EVENTS
Framework

Ò  Leaders adopt a framework that:

1.  Risk identification
Risk  
2.  Risk prioritization, Iden=fica=on  

3.  Risk reporting

4.  Risk management
Risk  
Assessment  

5.  Investigation of adverse events

6.  Management of related claims Risk  
Reduc=on  
Ò  Conducts and documents a pro-
active risk reduction annually
Ò  Take action to redesign high-risk
processes based on analysis 31  

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STEP 1: ESTABLISH RISK MANAGEMENT PROGRAM

Ò  Examples:
É  Sub-committee of the overall QIPS
program
É  A risk management coordinator
integrated into the QIPS program
Ò  Need to ensure organization-wide,
interdisciplinary representation.

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STEP 2: IDENTIFY ORGANIZATION-WIDE HIGH RISKS

PROCESSES

Ò  Sources of information:

É  Patient complaints
É  Incident reports (QPS)
É  Medication error reports (MMU.7.1)
É  Adverse event (medical error) monitoring
(QPS.6-8)
É  Environmental assessments (FMS.3.1)
É  INfection control assessments (PCI.5)
É  Insurance or legal claims
É  Safety walks or tracers

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CATEGORIES OF HIGH RISK PROCESSES

• Types of infections, including organisms of

epidemiological significance
• At-risk patient or resident populations
• Supplies and equipment risks
• Emergency preparedness
• Environmental issues
• Geographic considerations
• Community considerations
Identify specific risk process
In each category

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IS THIS A HIGH RISK PROCESS?

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STEP 3: PREPARE A PRIORITIZED LIST OF HIGH

RISK PROCESSES

Ò  Have leaders use prioritization criteria to

prepare list
Ò  List should reflect high risk process
processes for which failure has or will result
in harm to patients, staff, visitors, or contract
workers

You need standardized numerical values or criteria

to assess risks!!!
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RISK RANKING AND PRIORITIZATION METHODS

Ò  List each high risk process

Ò  For each high risk process, assign a
score (H,M,L) for each prioritization
criteria
Ò  Create a ranked prioritize list of high risk
processes

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RISK RANKING AND PRIORITIZATION CRITERIA

Ò  Usual  prioriKzaKon  criteria  are:  

É Probability  or  likelihood  of  occurrence  

É Risk  of  harm  (criKcality)  or  impact  

É System  capacity  or  preparedness  

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RISK RANKING AND PRIORITIZATION CRITERIA

Ò  Sometimes criteria given numerical

weight of 1-5 or 1-10 (refer to prioritization tool)
Ò  Each criteria scored as low, medium, or
high which is 1,3,5 or 1,5,9, or scored
from 1-10

Assigning numbers to ordinal scales

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PRIORITIZATION TOOL
 
Rangking  

 
 
Criteria Score
 
 
 
Probability : Dampak terhadap risiko Sistem Kontrol saat ini /
4 = Sering Terjadi 5 = Meninggal Preparedness
3 = Mungkin terjadi 4 = Cedera permanen 5 = Kuat / Solid
2 = Jarang terjadi 3 = Cedera reversibel / LOS>> 4 = Baik / Good
1 = Sangat jarang 2 = Cedera ringan 3 = Cukup / Fair
0 = Tidak mungkin terjadi 1 = Tidak Cedera 2 = Kurang
1 = Tidak ada / None 40  

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IDENTIFIKASI  PROSES  RISIKO  TINGGI  

RANGKING ANALISA
PRIORITAS RISIKO
NO IDENTIFIKASI PROSES RISIKO TINGGI RISK ASSESSMENT RISIKO PROAKTIF
Probability /
Komponen Program Situasi likelihood Impact Preparedness Total Score risk FMEA / HVA
(0-4) (1-5) (1-5)

Dampak terhadap risiko

Probability : 5 = Meninggal
4 = Sering Terjadi Sistem Kontrol saat ini
3 = Mungkin terjadi 4 = Cedera permanen 5 = Kuat / Solid
2 = Jarang terjadi 3 = Cedera reversibel / LOS memanjang 4 = Baik / Good
1 = Sangat jarang 3 = Cukup / Fair
0 = Tidak mungkin terjadi 2 = Cedera ringan
2 = Kurang
1 = Tidak Cedera 1 = Tidak ada / None 41  

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STEP 4: USE PROACTIVE RISK REDUCTION TOOL

FOR ANALYSIS AND PRIORITIZATION

Ò  Tools:
É  FailureMode Effect Analysis- FMEA
É  Healthcare Failure Mode Effect Analysis –
HFMEA
É  Hazard Vulnerability Analysis - HVA

Ò  Apply analysis tool to a list of high risk

processes, starting with the highest
priority

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STEP 5: DEVELOP AND IMPLEMENT SOLUTIONS

Ò  Itis the job of management not only to

assess risk, but also to identify effective
courses of action to eliminate or mitigate
that risk
Ò  This commitment to implementing risk
reduction methods transforms risk
assessment into risk management
Ò  Use a FMEA/RCA method to identify root
causes and potential solutions

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