Understanding Systems and The Impact

of Complexity on Patient Care

(Memahami Sistem dan Dampak Kompleksitas Sistem terhadap pelayanan /
Perawatan Pasien)

Meeting 6
By Romiko
 Crucial Point

Semakin kompleks suatu sistem, semakin tinggi kemungkinan terjadinya

kesalahan.
Pendekatan tradisional fokus pada individu/perorangan (naming, blaming,
shaming, retraining) bila terjadi kejadian tidak diinginkan atau kesalahan
dalam pelayanan.
Untuk mencegah terjadinya kejadian tidak diinginkan atau kesalahan
perlu dilakukan pendekatan sistem yaitu dengan memahami secara
keseluruhan bagaimana dan mengapa suatu kesalahan terjadi.
Suatu kejadian tidak diinginkan atau kesalahan bersifat multifaktor
(faktor pasien, penyedia pelayanan kesehatan, tugas, teknologi, alat, tim
pelayanan kesehatan, lingkungan, dan organisasi)
Swiss cheese model untuk penelusuran akar masalah.
 Human Factors Analysis and
Classification System
(HFACS)
Organizational
Factors

Unsafe
Supervision
Pre-
Conditions
for
Unsafe
Acts
Unsafe
Acts
Swiss Cheese Model
 UNSAFE
ACTS

Errors Violations

Skill-based Decision Perceptual

Routine Exceptional
Errors Errors Errors

Unsaf
e
Acts
 PRECONDITIONS
FOR
UNSAFE ACTS

Substandard Substandard
Conditions of Practices of
Operators Operators

Adverse Physical/ Crew Non-Supervisory

Adverse Personal
Physiological Mental Resource Tolerance of
Mental States Readiness
States Limitations Management Unsafe Acts

Preconditions
for
Unsafe Acts

Unsafe
Acts
 UNSAFE
SUPERVISION

Unforeseen Known

Unrecognized Inadequate Planned Failure to

Inadequate Supervisory
Hazardous Documentation/ Inappropriate Correct
Supervision Violations
Operations Procedures Operations Problem

Unsafe
Supervision

Preconditions
for
Unsafe Acts

Unsafe
Acts
 ORGANIZATIONAL
INFLUENCES

Resource Organizational Operational

Management Climate Process

Organizational
Influences

Unsafe
Supervision

Preconditions
for
Unsafe Acts

Unsafe
Acts
 Human Factors Analysis
Provides More than just an
Accident Investigation Tool
Organizational
Factors
Opportunity for
Pro-active Action
Unsafe
Supervision by Management

Preconditions
for
Unsafe Acts

Unsafe
Acts
Failures in your
Systems Defenses
Thanks.....