CURRICULUM VITAE

DATA PRIBADI
Nama
: dr.ADIB ABDULLAH YAHYA,MARS
Pangkat
: Brigjen TNI (Purn)
Tempat/tanggal lahir : Magelang,16 Februari 1949
Jabatan
: President Asian Hospital Federation
Agama
: Islam
ALAMAT : Jl. Punai H-24,Kel.Tengah,Jakarta Timur 13540
Telp
: (021)8404580
Fax
: (021) 8408047
HP

E-MAIL

(AHF)

08161803497
adibabdullahyahya@yahoo.com

PENDIDIKAN UMUM
SMA Negeri Magelang 1966
S1 : Fakultas Kedokteran Universitas Gajah Mada (UGM),
Yogyakarta, 1973
S2 : Fakultas Kesehatan Masyarakat, Universitas Indonesia (UI), Jakarta,
Program Kajian Administrasi Rumah Sakit ( KARS )

PENDIDIKAN MILITER
Sekolah Staf dan Komando TNI Angkatan Darat (SESKOAD), 1987/1988

PELATIHAN
Combined Humanitarian Assistance Response Training, oleh Singapore Armed Forces (SAF), Singapura, 2000
Health as a Bridge for Peace Workshop, oleh World Health Organization (WHO), Yogyakarta, 2000

PENGALAMAN JABATAN
Komandan Detasemen Kesehatan Pasukan Pengamanan Presiden (DanDenkes Paspampres),
1987-1991
Kepala Rumah Sakit Muhammad Ridwan Meuraksa, Jakarta, 1992
Kepala Kesehatan Daerah Militer (Kakesdam) Jaya, Jakarta, 1993
Komandan Pusat Pendidikan Kesehatan TNI AD,1995 1999
Wakil Kepala Pusat Kesehatan TNI, 1999 2000
Kepala RSPAD Gatot Soebroto, 2000 2002
Dekan Fakultas Kedokteran UPN, Jakarta, 2000 2002
Wakil Ketua Tim Dokter Kepresidenan RI, 2000 2002
Direktur Kesehatan TNI Angkatan Darat (Dirkesad), 2002-2004
Wakil Ketua Tim Pemeriksaan kesehatan untuk calon Presiden dan calon Wakil Presiden RI
Th.2004
DOSEN Pasca Sarjana FKM UI, Kajian Administrasi Rumah Sakit (KARS)
DIREKTUR UTAMA RUMAH SAKIT MMC

ORGANISASI
Ketua Ikatan Rumah Sakit Jakarta Metropolitan (IRSJAM), 2000-2003
Ketua Umum Perhimpunan Rumah Sakit Seluruh Indonesia ( PERSI), 2003-2009)
Ketua Tim Kajian Globalisasi IDI Pusat.
Anggota Komnas FBPI.
Angggota TNP2K.
Ketua Divisi Kemahkamahan Majelis Kehormatan Etik Kedokteran (MKEK) IDI Pusat
Tim Konsultan Institut Manajemen Risiko Klinis ( IMRK )
Koordinator Bidang 1 : KAJIAN KESELAMATAN PASIEN, KKPRS
Instruktur HOPE ( Hospital Preparedness for Emergencies and Disasters}
PRESIDENT OF ASIAN HOSPITAL FEDERATION ( AHF ) 2009 2011

PATIENT SAFETY IS A KEY COMPONENT OF

RISK MANAGEMENT

Dr. ADIB A YAHYA, MARS

PRESIDENT
ASIAN HOSPITAL FEDERATION
( AHF )
WORKSHOP KESELAMATAN PASIEN DAN MANAJEMEN RISIKO KLINIS
DI RUMAH SAKIT

1. What?
3. How?
2. Why?
4

What ?

DEFINISI RISIKO
RISIKO ADALAH :
POTENSI TERJADINYA KERUGIAN

YANG DAPAT TIMBUL DARI PROSES

KEGIATAN SAAT SEKARANG ATAU
KEJADIAN DIMASA DATANG.

ERM, Risk Management Handbook for Health Care Organization

Risiko di Rumah Sakit

RISIKO KLINIS :
SEMUA ISU YANG DAPAT BERDAMPAK
TERHADAP PENCAPAIAN PELAYANAN PASIEN
YANG BERMUTU TINGGI,AMAN DAN EFEKTIF.

RISIKO NONKLINIS/ Corporate Risk :

SEMUA ISSU YANG DAPAT BERDAMPAK
TERHADAP TERCAPAINYA TUGAS POKOK
DAN KEWAJIBAN HUKUM DARI RUMAH SAKIT
SEBAGAI KORPORASI.
7

KATEGORI RISIKO DI RUMAH SAKIT :

( Categories of Risk )
Patient care-related risks
Medical staff-related risks
Employee-related risks
Property-related risks
Financial risks
Other risks

Risiko yang berhubungan dengan perawatan pasien

(Patient care related risks)
Direct association with patient care
Consequences of inappropriate or incorrectly performed
medical treatments
Confidentiality and appropriate release of information
Protection from abuse, neglect and assault
Was patient informed of risks?
Nondiscriminatory treatment
Appropriate triage and transfer of patients from ER
Patient participation in research studies and use of experimental
drugs - was consent obtained?
Was patient discharged appropriately?

Risiko yang berhubungan dengan tenaga medis

(Medical staff - related risks)

- Credential terhadap staf medis ?

- Tindakan medis sesuai kompetensi dan prosedur baku ?

- Was patient properly managed ?

- Do we have adequately trained staff ?
10

Risiko yang berhubungan dengan karyawan

(Employee related risks)
- Risiko keselamatan dan kecelakaan kerja
- Maintaining a safe environment - Employee Health Policy :
. reducing risk of occupational illness and injury
. providing for the treatment and compensation of
workers for work-related illnesses or injuries

11

Risiko yang berhubungan dengan property

(Property related risks)

Protect assets from losses due to fires, floods, etc

Paper and/or electronic records - patient, business
and financial - protected from damage or
destruction
Procedures for handling cash and safeguarding
valuables
Bonding and insurance to protect facility from
losses
12

Risiko keuangan
(Financial risks)

Bad Debt
Meningkatnya suku bunga
Global Financial tsunami

13

Risiko lain
(Other risks)

- Hazardous material management :

chemical, radioactive, infectious biological
waste management

- Legal & regulatory risks

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WHY ?

15

HOSPITAL
System made up of thousands of
inter-linked processes..
things can go wrong

16

Errors are inevitable

.but most are preventable

17

HOW ?

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DIDALAM SISTEM KITA YANG SANGAT KOMPEKS INI ..

BAGAIMANA KITA AKAN MENDARAT DENGAN SELAMAT ?
BAHAYA / HAZARD / RISIKO YANG MANA
YANG HARUS KITA TANGANI TERLEBIH DAHULU ?

19

MANJEMEN RISIKO
. . . ADALAH PENDEKATAN PROAKTIF
UNTUK MENGIDENTIFIKASI,MENILAI
DAN MENYUSUN PRIORITAS RISIKO,
DENGAN TUJUAN UNTUK
MENGHILANGKAN ATAU
MEMINIMALKAN DAMPAKNYA.
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RISK MANAGEMENT PROCESS

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PROSES MANAJEMEN RISIKO

IDENTIFIKASI RISIKO

ANALISA RISIKO
ASESMEN RISIKO
EVALUASI RISIKO

MONITOR DAN REVIEW

KOMUNIKASI DAN KONSULTASI

TEGAKKAN KONTEKS

KELOLA RISIKO
RISK REGISTER
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RISK MANAGEMENT TECHNIQUES/TREATMENTS

RISK CONTROL :
- EXPOSURE AVOIDANCE
- LOSS PREVENTION
- LOSS REDUCTION
- SEGREGATION (SEPARATION OR DUPLICATION)
- CONTRACTUAL TRANSFER FOR RISK CONTROL

RISK FINANCING :
- RISK RETENTION
- RISK TRANSFER
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IMPLEMENTASI
MANAJEMEN RISIKO KLINIK
DI RUMAH SAKIT

24

PRIMUM, NON NOCERE

FIRST, DO NO HARM

HIPPOCRATESS TENET
(460-335 BC)

Risiko SELALU MELEKAT dengan

proses pengobatan kepada
pasien itu sendiri

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RISIKO MENYATU DENGAN SEMUA ASPEK

PELAYANAN KESEHATAN,TERMASUK :

pengobatan dan perawatan kepada pasien;

menentukan prioritas pelayanan ;
pengembangan proyek dan pelayanan ;
pembelian obat dan produk kesehatan lain;
instruksi dan follow up kepada pasien.

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CRITICAL POINTS IN CLINICAL RISK MANAGEMENT

PROVIDING CARE IN THE EMERGENCY ROOM

MAKING A DIAGNOSIS
ORDERING INVESTIGATIONS AND INTERPRETING
THE RESULTS
UNDERTAKING INVASIVE PROCEDURES
DRUG TREATMENT
WARD MANAGEMENT

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RISK MANAGEMENT IN ER
POTENTIAL ERRORS

REDUCING/MINIMISING RISKS

Assessment of emergencies
by insufficiently experienced
junior staff
Inadequate use of specialist
opinion
Inadequate reading of simple
radiographs

Experienced clinicians available

full-time

Poor management of standard

situation
Inadequate assessment before
discharge

Use protocols with sensitivity

Involvement of specialist in the

training of staff
Training of staff
on call radiologist

Senior staff to take responsibility

for discharges
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REDUCING DIAGNOSTIC ERROR

POTENTIAL ERRORS
Failure to take a well-focused
case history
Failure to assess the
evidence & make a DD
Inappropriate use of tests

Leaving the problem

unexplained

REDUCING/MINIMISING RISKS

Concentrate on key elements

Better training
Write down conclusions before
making a plan

Define spesific quuestios to be

answered by chosen tests

Get a second opinion

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REDUCING THE RISKS OF INVESTIGATION

POTENTIAL ERRORS

REDUCING/MINIMISING RISKS

Clinician misreads visual

evidence e.g. x ray; ECG

Fully trained staff to interpret and

report on tests

Clinician not aware of lab results

Clinically important results to be

relayed to clinician urgently
Ward tests to be supervised and
results discussed with clinicians

Clinician not aware of ward

observation
Clinician fails to understand test
result

Aware of the limits of their

competence
Senior staff to check repeatedly

Inappropriate use of tests

Careful supervision

31

Reducing the risks of invasive procedures

Consider The risk : benefit ratio

Discuss the procedure with the patient
Carrying out the procedure including coping with
potential difficulties
Ensure that the equipment is in good working order
and that back up equipment is available
If the procedure is not going well obtain help / be
prepared to give up
Ensure that the operator has sufficient skill

32

Reducing the risks of invasive procedures

Consider The risk : benefit ratio

Discuss the procedure with the patient
Carrying out the procedure including coping with
potential difficulties
Ensure that the equipment is in good working order
and that back up equipment is available
If the procedure is not going well obtain help / be
prepared to give up
Ensure that the operator has sufficient skill

33

COMMON SPECIFIC FACTORS ASSOCIATED WITH

DRUG ADVERSE EVENTS
FAILURE TO TAKE ACCOUNT OF DECLINING
RENAL / HEPATIC FUNCTION
FAILURE TO CHECK FOR POSSIBLE ALLERGIC
RESPONSES
USING THE WRONG DRUG NAME OR MEANS OF
ADMINISTRATION
MISCALCULATION OF DOSAGE
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REDUCING THE RISKS OF ONGOING WARD CARE

POTENTIAL ERRORS

REDUCING.MINIMISING RISKS

Failure to monitor clinical

progress

Joint education regarding

appropriate monitoring

Failure to recognise that a

patient is not making
satisfactory progress

Regular supervision

Failure to provide appropriate

treatment

Use spesialist staff clinician

from appropriate unit, nurse
spesialist, physiotherapist

Shift working

Briefing & de-briefing

SBAR
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PATIENT SAFETY,QUALITY OF CARE

AND RISK MANAGEMENT

36

The basic principles for safety

and quality of care
The basic principles for patient safety are
the principles for quality of care:
- to do the right thing
for the right patient
using the right method and
at the right time, and
- to communicate well with the patient
and the rest of the clinical team
37

Its easy gettin good players.

The hard part is gettin them to play
with each other
(Casey Stengel)
(Casey

38

Communicating Team ???

39

Quality in Healthcare
. begins with ensuring patient safety

40

Key reasons
Patients are more at risk than non-patients
Medical interventions are, by their nature,
high-risk procedures - small error margins
Medicine remains an inexact, hands-on
endeavour

41

Patient safety in context

Patient safety is an important component of

risk management, clinical governance, and
quality improvement.

42

Australian Patient Safety Foundation

43

CONCLUSIONS
I.

Risk management is not primarily about avoiding or

mitigating claims; rather, it is a tool for

improving the quality of care .

II. Incident reporting is only one aspect of the identification of

risk. Incident reporting is on the reactive side of risk
management. More emphasis needs to be placed on

the proactive side.

III. Risk management is actually

the business of all stakeholders

the organisation, clinicians and nonclinicians.

in

IV. The primary focus of risk management should now be

clinical governance and patient

safety.

44

FINAL WORD

Safe care is not an option.

It is the right of every patient
who entrusts their care to our Healthcare systems
Sir Liam Donaldson,
Chair, WHO World Alliance for Patient Safety,
Forward Programme, 20062007

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TERIMAKASIH

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