Jalan Jenderal Sudirman No.

3, Sungailiat
Prov. Kepulauan Bangka Belitung, Indonesia 33211
Telepon: +62 (717) 95837, Fax: +62 (717) 93335

Rumah Sakit
Medika Stannia Sungailiat

FORMAT LAPORAN INSIDEN

KE TIM KESELAMATAN PASIEN RS. MEDIKA STANNIA
(RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAKSIMAL 2x24 JAM)
Laporan Kejadian Potensial Cedera Signifikan (KPCS)

1. Tanggal dan Waktu ditemukan Kejadian Potensial Cedera Signifikan (KPCS)

Tanggal : ............................................…
Jam : ...............................................

2. KPCS : ............................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

3. Orang Pertama Yang Melaporkan Insiden*

Karyawan : Dokter / Perawat / Petugas lainnya
Pasien
Keluarga / Pendamping Pasien
Pengunjung
Lain-lain ..................................................................................(sebutkan)

4. Lokasi diketemukan KPCS

.........................................................................................................................................
.........................................................................................................................................
........................................................... (sebutkan)

5. Unit terkait KPCS

.........................................................................................................................................
............................................................................. (sebutkan)

6. Tindakan yang dilakukan selama ini, dan Hasilnya :

.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
........................................................................................................................................

7. Tindakan dilakukan oleh* :

Tim : terdiri dari : ..................................................................................................
Dokter
Perawat
Petugas lainnya : .................................................................................................
 Jalan Jenderal Sudirman No. 3, Sungailiat
Prov. Kepulauan Bangka Belitung, Indonesia 33211
Telepon: +62 (717) 95837, Fax: +62 (717) 93335

Rumah Sakit
Medika Stannia Sungailiat

8. Apakah kejadian yang sama pernah terjadi di Unit Kerja lain?*

Ya Tidak

Apabila Ya, isi bagian dibawah ini.

Kapan? ......................................................................................................................
Dan Langkah/tindakan apa yang diambil pada Unit kerja tersebut untuk mencegah
terulangnya kejadian yang sama?
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................

Pembuat Penerima
Laporan Laporan
Paraf Paraf

Tanggal Terima Tanggal Lapor

NB. *= pilih satu jawaban