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Patient Safety

&
TOTAL CARE
Aryono D. Pusponegoro
Kolegium Ilmu Bedah Indonesia

MENGAPA PERLU PATIENT


SAFETY

In a Hospital :
Because there are
hundreds of
medications, tests
and procedures,
and many patients
and clinical staff
members in a
hospital, it is quite
easy for a mistake
to be made. . . .

Di Rumah Sakit :
banyaknya jenis obat,jenis
pemeriksaan dan prosedur, serta
jumlah pasien dan staf Rumah Sakit
yang cukup besar, merupakan hal yang
potensial bagi terjadinya
kesalahan.

KESALAHAN MEDIS (Medical Error)


yang terjadi dalam proses
asuhan medis yang mengakibatkan
atau berpotensi mengakibatkan
cedera pada pasien.

Kesalahan

(KKP-RS)
TOTAL CARE

KEJADIAN TIDAK DIHARAPKAN (KTD)/


Adverse Event
kejadian yang mengakibatkan
cedera yang tidak diharapkan pada
pasien karena suatu tindakan
(commission ) atau karena tidak
bertindak (ommision ), dan bukan
karena underlying disease atau
kondisi pasien (KKP-RS).

Suatu

NYARIS CEDERA (NC)/ Near Miss


Suatu kejadian akibat melaksanakan suatu
tindakan (commission) atau tidak mengambil
tindakan yang seharusnya diambil (omission),
yang dapat mencederai pasien, tetapi cedera
serius tidak terjadi, karena :
keberuntungan(mis.,pasien terima suatu obat
kontra indikasi tetapi tidak timbul reaksi obat),
karena
pencegahan (suatu obat dengan overdosis lethal
akan diberikan, tetapi staf lain mengetahui dan
membatalkannya sebelum obat diberikan), atau
peringanan (suatu obat dengan over dosis lethal
diberikan, diketahui secara dini lalu diberikan
antidotenya).(KKP-RS)

Pasien
tidak cidera

- Dpt obat c.i., tdk timbul (chance)


- Plan, diket, dibatalkan (prevention)
- Dpt obat c.i., diket, beri anti-nya

-Kesalahan proses
-Dpt dicegah
-Pelaks Plan action
Pasien
tdk komplit
cidera
-Pakai Plan action yg
salah
-Krn berbuat : commission
-Krn tidak berbuat : omission

(Non Error)

(NM)

(KNC=Kejadian NYARIS CIDERA)

Proses of Care
Error

Proses of Care

Near Miss

Pasien
cidera

(mitigation)

Adverse Event

(AE)

(KTD=Kejadian Tdk Diharapkan)

Adverse Event

Dimana Kemungkinan Kesalahan Bisa


Terjadi?
Diagnostik
Kesalahan atau keterlambatan diagnose
Tidak menerapkan pemeriksaan yang
sesuai
Menggunakan cara pemeriksaan yang
sudah tidak dipakai
Tidak bertindak atas hasil pemeriksaan
atau observasi

Pengobatan
Kesalahan pada prosedur pengobatan
Kesalahan pada pelaksanaan terapi
Kesalahan metode penggunaan obat
Keterlambatan merespon hasil
pemeriksaan

Preventive
Tidak memberikan terapi profilaktik
Monitor dan follow up yang tidak
adekuat

Lain-lain :
Kegagalan berkomunikasi
Kegagalan alat
Kegagalan sistem lain

TO ERR IS HUMAN CORRIGAN, KOHN AND DONALDSON


US ACADEMY OF SCIENCES / INSTITUTE OF MEDICINE,
2000
1984 New York, 2.9% of admissions suffered an adverse

event, 58% of which were preventable

1992 Colorado and Utah, 3.7% of admissions suffered an


adverse event, 53% of which were avoidable
Over 33.6Mn US hospital admissions pa, between 44,000
and 98,000 avoidable deaths occur
8th most frequent cause of death
ahead of AIDS (16,516 deaths pa),
breast cancer (42,297 deaths pa) and
motor car accidents (43,458 deaths pa)
Total cost to the US economy of avoidable deaths due to
healthcare error $17 - $29 Bn pa
HRRI, Healthcare Risk Resources International

WHO
- Pada World Health Assembly ke 55 Mei 2002
ditetapkan suatu resolusi yang mendorong (urge)
negara untuk memberikan perhatian kepada
problem Patient Safety meningkatkan
keselamatan dan sistem monitoring
Okt 2004 WHO dan berbagai lembaga
mendirikan
World Alliance for Patient Safety dgn tujuan
mengangkat Patient Safety Goal
First do no harm dan menurunkan morbiditas,
cidera dan kematian yang diderita pasien

Patient Safety di berbagai negara


1. Amerika : AHRQ (Agency for Healthcare
Research and Quality), 2001
2. Australia : Australian Council for Safety and
Quality in Health Care, 2000
3. Inggeris : NPSA
(National Patient Safety Agency), 2001
4. Canada : NSCPS (National Steering
Committee on Patient Safety);
CPSI (Canadian Patient Safety Institute), 2003
5. Malaysia : Patient Safety Council, 2004
6. Denmark : UU Patient Safety, 2003
7. Indonesia : KKP-RS, 2005

DI INDONESIA ?
-The cockroach theory : For every one you
see, hundreds more are hiding in the
woodwork !
-Our hospital are very safe and a couple of
accidents are acceptable
- Masih di daerah Blaming yang sangat
costly dan menjauhkan pasien dari rumah
sakit
- Litigious Society defensive medicine

Mengapa Patient Safety


Quality

Structure

Quality

Process of care

Cost: Invsment

Patient Safety
-Culture
-Reporting
-Learning/Analysis/Research
-K&R-based Standard-Guideline
-Implementasi,Monitor
-Patient Involvement
Kepercayaan meningkat

Quality

Outcome

: AE

Costly

Blaming
-Tuduhan Malpraktek(Pid/Perd)
-Proses Hukum:Polisi,Pengadilan
-Blow-up Mass Media, 90%
Publikasi-opini negatif
-Pengaduan, Tuntutan
-Pertahanan RS :
-Pengacara
-RS/Dr : Asuransi
-Tuntutan balik
- Dsb

Kecurigaan meningkat
Nico A. Lumenta/KKP-RS

Patient Safety

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

Keselamatan Pasien
(Patient safety)
Suatu sistem yang mendorong rumah sakit
membuat asuhan pasien menjadi lebih aman.
Sistem ini mencegah terjadinya cedera yang
disebabkan oleh kesalahan akibat melaksanakan
suatu tindakan atau tidak mengambil tindakan
yang seharusnya diambil.
(KKP-RS)

PRIMUM, NON NOCERE


FIRST, DO NO HARM

HIPPOCRATES TENET
(460-335 BC)

Total Care :

I bandaged him (I make the


wound), but GOD healed him

1545

Ambroise Pare

Total Care :
Don let me don.
Dopamin.

Terapi simptomatik
Tanda2 vital ????
Sel ????

Total Care :

Prof. Sjamsuhidajat (1987)

TOTAL CARE

TOTAL CARE :
Patofisiologi.
Organ

Anatomi
Makro sirkulasi.
Sel
Mikro sirkulasi.
Listen
To What The Cells Say !!!!

Total Care :
10 Butir Total Care :
1. Triage ?
2. Diagnosa ?
3. Kasus bedah / bukan ?
4. Masalah yang dapat timbul ?
5. Jenis op. / teknik op. ( School Of Surgery /
School Of Anesthesiology) ?
6. Timing operasi ?
7. Masalah prabedah ?
8. Masalah intrabedah ?
9. Masalah pascabedah ?
10. Follow Up ?
STRATEGIC THINKING !!!

Total Care :
TRIAGE ?
Primary Survey :
A ( Airway ).
B ( Breathing ).
C ( Circulation ).
D ( Disability ).
E ( Exposure Hipotermi).
Resusitasi bedah
Stop Bleeding .
Stop Contamination .
Damage Control
Surgery!!!
1.

Total Care :

2. DIAGNOSA :
Anamnesa M Mech. Of Injury .
I Injury Sustained .
S Symptoms
T Therapy .
Pemeriksaan f isik Cari Injury & Symptoms
Back To Basics .
Nutritional assessment (Body
composition, Biochemical data,
Subj. Global Assessment - SGA)
& Screening.
Laboratorium
Metabolisme anaerob ????
Listen To What The Cells Say .
Gizi : Serum albumin, Total lymph
count, Serum transferin, Serum
pre albumin, Total iron binding
capacity , cholesterol
Imajing Foto polos, USG, CT Scan, MRI & MSCT dll.
Endoskopi / Laparoskopi D/ & PA.

Total Care :

3. Kasus bedah / bukan ?

Total Care :

4. MASALAH YG DPT TIMBUL ?


Otak ?
Pernafasan ?
Kardiovaskuler ?
Hati ?
Ginjal ?
Pankreas ?
Consumption Coagulopathy,
Surg./ Non Surg. Bleeding ?
Gut Failure ? Lambung / Ileus.
Gizi ? Normal,
Malnutrisi sedang (9%
komplikasi),
Malnutrisi berat ( 42% komplikasi)
Imunologi SIRS, CARS, MARS ?
Strategic Thinking !!!

Total Care :
5. JENIS TINDAKAN /
TEKNIK
OPERASI ?
School of Surgery ?
School of Anesthesiology ?
1, 2, 3 & 4
Informed Consent .
Communication Skill !!!

Total Care :
6. TIMING OPERASI ?
Gawat Darurat ?
Segera ?
Tunda ?
Konservatif ?
Elektif ?

Total Care :
7. MASALAH PRA BEDAH ?
Hernia Strangulata 3 hari / 1 Hari ?
Masalah A, B, C ?
Resp Distress ?
Compartment Syndrom?
Metabolisme, elektrolit,
asam-basa?
Toleransi operasi ???
Strategi berubah !!!

Total Care :
8. MASALAH INTRA BEDAH ?
Fasilitas kmr operasi ?
Teknik operasi ?
Mampukah saya ???
Teknik anestesi mana & dampaknya ?
Hanya resusitasi bedah / definitif ?
Op elektif Triad Of Death
Damage Control
Surgery?
Nutrisi Teknik operasi (Feeding
jejunostomi ?)

Total Care :
9. MASALAH PASCA BEDAH ?
Evaluasi butir 1 8 ?
A? B? C? D? E
(Hipotermi) ?
Listen To What The Cells Say
Ruangan bedah ?
SICU / HCU ?
ICU / ICCU ?
MASALAH SEL ???
Mikrosirkulasi ???

Total Care :
10. FOLLOW UP ?
Di bangsal : A ( Airway ) ?
B ( Breating ) ?
C ( Circulation ) ?
D ( Disability ) ?
E (Hipotermi) ?
Listen To What The Cells Say !!!!
Di poli :
Apakah EQUILIBRIUM (Claude Bernard)
sdh dicapai ?

BLAMING ?

SUPPORTING?

Hypotensive
Resuscitation in the
Pre Hospital & ER
Phase
Aryono D.Pusponegoro

Refferal :
ATLS
Acute Care Surgery
Peri Op Critical Care
Total Care
Pusponegoro A.D.

28 yrs Police
5 AM taken by
Taxi to Small Hosp
Bleeding (-)
Alert,
BP 80/65
Stable
PR 90 / Min
2 L RL Bleeding
(+)
Shock (+)
12.00 Consulted to
Surgeon
Triad of Death (+)
Damage Control
Surgery
Rewarming
16.00

Deadly Dozen :
Lethal Six :
1. Airway Obstruction
2. Tension
Pneumothorax
3. Cardiac
Tamponade
4. Open
Pneumothorax
5. Masive
Hemothorax
6. Flail Chest

Hidden Six :
1. Thoragic Aorta
Disruption
2. Tracheobronchial
Injury
3. Blunt Cardiac
Injury
4. Diaphragmatic
Injury
5. Esophageal Injury
6. Pulmonary
Contusion

ATLS

Source of Bleeding Shock :


1.
2.
3.
4.
5.

Thorax
Abdomen
Pelvis
Femur
Retro Peritoneal

Patient in Hemorhagic Shock


Resuscitated according to Protocal
with 2000 cc RL
Shock ???
ATLS
1. Rapid Response
2. Transient Response ???
3. No Response
Why ???

The American College of


Surgeons protocol for
ATLS, recommends :

THE TRADITIONAL APPROACH of the emergency


physician and the trauma surgeon (civilian
setting), hypovolemic hypotension is to correct
any traumatic as rapidly as possible.
This emphasis on immediate post-injury fluid
resuscitation was based on early experimental
data showing that rapid restoration of blood
volume and pressure led to improvement of vital
organ function and long term survival , by
avoiding the late sequelae of hypovolemic shock.
ATLS Course promotes the rapid infusion of
large volumes of crystalloids to hypotensive
trauma patients.

Opponents to The ATLS


concept
(1)

Solomonov et al and Krauz et al


(1990): Independently showed,
that in an experimental sheep
model of spleen injury, with
uncontrolled hemorrhage,
vigorous infusion of isotonic
and hypertonic saline to
achieve a normal blood
pressure resulted in increased
bleeding and mortality.

Opponents to The ATLS


concept (2)

Stern and colleagues (1993) : showed


in a porcine model with abdominal
aortic injury with near fatal
hemorrhage, that attempts to restore
blood pressure with rapid infusion of
crystalloids led to increased bleeding
and mortality.
Capone and associates : also
confirmed this adverse result in a
murine model, and showed that
judicious fluid administration improved
short-term survival.

Early vs Delayed Resuscitation


(Bickell, N. Eng. J. med 1994)

Bickell noted that rapidly


administering Lactated Ringer's
solution intravenously
significantly increases
hemorrhage and death p<0.05.
The increased volume of
hemorrhage in the resuscitated
group could have resulted from
either accentuation of an ongoing
hemorrhage of reinitiating the
hemorrhage after spontaneous
hemostasis had occurred.

USUHS / Uniformed Services


University of the Health
Sciences (USA 2001)

I st Conference of USUHS,
Recommended :
Consensus of resuscitation endpoints

i. a palpable radial pulse,


ii. ability to mentate, and
iii. sustained a systolic blood
pressure 85-90 mmHg (if
sphygmomanometry was
available).

HYPOTENSIVE RESUSCITATION

This technique calls for fluid


administration, endpoint :
i. MAP (mean arterial pressure) of 60
mm Hg or,
ii. SBP (systolic blood pressure) of 90
mm Hg,
the minimum pressure necessary to
maintain vital organ perfusion.
Hypotensive resuscitation has been
advocated in order to prevent the
resuscitation re-bleeding injury
mentioned above.

Blood Pressure at which Rebleeding


Occurs after Resuscitation in Swine with
Aortic Injury
(Sondeen, J Trauma 2003 Vol 54)

There was a reproducible pressure at


which rebleeding occurs

The rebleeding occurs was not affected by time (515) minute or by the rate (100 vs 300 ml/minute), but
:

The average pressure at the rebleeding was


MAP 64 + 2 mmHg
Systolic 94 + 3 mmHg
Diastolic 45 + 2 mmHg
Conclusions : The optimal

endpoint of
resuscitation for uncontrolled
bleeding should be below the
rebleeding pressure

During Transport Keep the


Patient Hypotensive under the
Rebleeding Point
If Surgeon (-) Keep the PT
Hypotensive until the Surgeon
arrives
Arrival in the ER Go Straight
to the Operating Room or Do an ER
Laparotomy / Thoracotomy to Stop
the Bleeding then Resuscitate
Dont waste your time in the
Resuscitation Room with Fluids !!!