Go nical
ve r
na n
ce
s k nt
Ri eme
ag
an
M
Patient
Safety
Quality
Improvement
HIPPOCRATESS TENET
(460-335 BC)
KTD
(Pasien Cedera)
Hasil
Fisik
Psikis
Dampak
Keparahan
Durasi
1A
1B
Communication problems
Inadequate information flow
Human problems
Patient-related issues
Organizational transfer of knowledge
Staffing patterns / work flow
Technical failures
Inadequate policies and procedures
(AHRQ Publication No 04-RG005, december 2003.)
-Agency for Healthcare Research and Quality-
Hand Hygiene
Additional Resources
WHO Guidelines on Hand
Hygiene in Health Care
Learning objective
The objective of this topic is to
understand the main causes of
adverse events in surgical care and
how they can be reduced by applying
verification processes to ensure the
correct patient receives the right
procedure at the right time and place
Performance
requirements
follow a verification process to
eliminate wrong patient, wrong side
and wrong procedure
practise operating room techniques
that reduce risks and errors ( timeout, briefings, debriefings, stating
concerns)
participate in an educational process
for reviewing surgical mortality and
morbidity
Knowledge
requirements
the main types of adverse events
associated with surgical and
invasive procedural care
the verification processes for
improving surgical and invasive
procedures care
Learning Method
Interactive Lecture
Panel Discussion
Small Group Discussion
Simulation Exercise
Operating Theatre and Ward
Activities
INTRODUCTION TO
SURGICAL SAFETY
Rationale
medication use has become
increasingly complex in recent
times
medication error is a major cause of
preventable patient harm
as future doctors, you will have an
important role in making
medication use safe
Learning objectives
Knowledge requirements
understand the scale of medication
error
understand the steps involved in a
patient using medication
identify factors that contribute to
medication error
learn how to make medication use
safer
understand a doctors responsibilities
when using medication
Performance requirements
Acknowledge that medication safety is a big topic and an
understanding of the area will affect how you perform the
following tasks:
Introduction to Medication
Safety
definitions
side-effect: a known effect, other than that
primarily intended, relating to the
pharmacological properties of a medication
e.g. opiate analgesia often causes nausea
adverse reaction: unexpected harm arising
from a justified action where the correct
process was followed for the context in which
the event occurred
e.g. an unexpected allergic reaction in a
patient taking a medication for the first time
error: failure to carry out a planned action as
intended or application of an incorrect plan
adverse event: an incident that results in
harm to a patient
WHO: World alliance for patient safety taxonomy
wrong patient
wrong route
wrong time
wrong dose
wrong drug
omission, failure to administer
inadequate documentation
The 5 Rs
right
right
right
right
right
drug
route
time
dose
patient
Trigger
Trigger I
Trigger II
Trigger III
Trigger IV
Seorang pasien wanita usia 50 tahun datang ke
poliklinik mata dengan keluhan mata kanan kabur.
Dari pemeriksaan, Dokter menegakkan diagnosis
katarak senilis, dan pasien dianjurkan untuk operasi.
Di kamar pre op pasien ditetesi obat anestsi topikal
oleh petugas, tetapi matanya menjadi merah dan
edema. Operasi hari itu dibatalkan, pasien
dipulangkan dan disuruh kembali 2 minggu lagi.
2 minggu kemudian pasien datang kembali dan
diterima oleh petugas yang berbeda dengan yang
pertama, dan terjadi lagi proses yang sama, mata
pasien ditetes obat dan terjadi lagi merah dan
bengkak.
Trigger IV
Berdasarkan gambaran kasus di atas, jawab dan diskusikan dengan
kelompok Anda mengenai:
a. Mungkinkah kesalahan dalam peresepan (prescribing)
menyebabkan terjadinya masalah pada kasus di atas?
Diskusikan dengan kelompok Anda mengenai cara menghindari
kesalahan dalam peresepan obat-obatan!
b. Mungkinkah kesalahan dalam proses pemberian
(administarting) menyebabkan terjadinya masalah pada kasus
di atas? Diskusikan dengan kelompok Anda mengenai cara
menghindari kesalahan dalam proses pemberian obat-obatan!
c. Mungkinkah kesalahan dalam melakukan monitoring obatobatan menyebabkan terjadinya masalah pada kasus di atas?
Diskusikan dengan kelompok Anda mengenai cara menghindari
kesalahan dalam melakukan monitoring obat-obatan!
PLENO &
PEMBAHASAN
MATERI
........
THANK YOU