Analisis Resiko dan

Treatment Medication
Error
Seperti kita ketahui dalam
pembahasan sebelumnya:
 Failure Mode Analysis (FMA)
 Failure Mode and Effect Analysis (FMEA)
 Human Error Mode And Effect Analysis
(HEMEA)

Peran Manajemen Resiko dalam Pencegahan

Medication Error
Selanjutnya…

 Kita akan membahas tentang:

Treatment Medication
Error
Definisi

Treatment Medication Error

adalah usaha yang dilakukan
untuk meminimalisir atau
meniadakan efek setelah ME
terjadi.
 Usaha usaha yg dapat dilakukan
misalnya:
 Being A Team Player & Showing Leadership
 Understanding Human Factors
 Understanding Complex Organizations
 Providing Continuty Of Care
 Managing Fatique and Stress
 Maintaining Fitness to Work or Practice
 Professional & Ethical Behaviour
 Preventing Wrong Site, Wrong Procedure and wrong
Patient Treatment
 Recognizing, Reporting & Managing Adverse Events &
Near Misses
 Continuing Learning
 Workplace Learning
 Workplace Teaching
 How to Reduce Your Risk
 Safe Handover For Clinicians and
Managers
 
Ingat bahwa pasien safety
sangat penting dan jangan
abaikan.
 PENERAPAN
KESELAMATAN PASIEN
RUMAH SAKIT
1). TUJUH LANGKAH MENUJU
KESELAMATAN PASIEN RUMAH SAKIT

2). STANDAR KESELAMATAN PASIEN

RUMAH SAKIT
 1
KKP-RS NO 001-VIII-2005

TUJUH LANGKAH MENUJU

KESELAMATAN PASIEN
RUMAH SAKIT
PANDUAN BAGI STAF RUMAH SAKIT
(KKP-RS)
7 LANGKAH
 BANGUN KESADARAN AKAN NILAI KP, Ciptakan kepemimpinan &
budaya yg terbuka & adil.
 PIMPIN DAN DUKUNG STAF ANDA, Bangunlah komitmen & fokus
yang kuat & jelas tentang KP di RS Anda
 INTEGRASIKAN AKTIVITAS PENGELOLAAN RISIKO, Kembangkan
sistem & proses pengelolaan risiko, serta lakukan identifikasi &
asesmen hal yang potensial bermasalah
 KEMBANGKAN SISTEM PELAPORAN, Pastikan staf Anda agar dgn
mudah dapat melaporkan kejadian / insiden, serta RS mengatur
pelaporan kpd KKP-RS.
 LIBATKAN DAN BERKOMUNIKASI DENGAN PASIEN, Kembangkan
cara-cara komunikasi yg terbuka dgn pasien
 BELAJAR & BERBAGI PENGALAMAN TTG KP, Dorong staf anda
utk melakukan analisis akar masalah untuk belajar bagaimana &
mengapa kejadian itu timbul
 CEGAH CEDERA MELALUI IMPLEMENTASI SISTEM KP, Gunakan
informasi yang ada tentang kejadian / masalah untuk melakukan
perubahan pada sistem pelayanan
KKP RS
 2

STANDAR
KESELAMATAN PASIEN
RUMAH SAKIT

(KARS – DEPKES)
 Standar Keselamatan Pasien RS
(KARS – DepKes)
I. Hak pasien
II. Mendidik pasien dan keluarga
III. Keselamatan pasien dan asuhan
berkesinambungan
IV. Penggunaan metoda-metoda
peningkatan kinerja, untuk melakukan
evaluasi dan meningkatkan keselamatan
pasien
V. Peran kepemimpinan dalam
meningkatkan keselamatan pasien
VI. Mendidik staf tentang keselamatan pasien
VII. Komunikasi merupakan kunci bagi staf untuk
mencapai keselamatan pasien
KKP RS
 Active failures Latent Conditions

Errors

Near Misses Patient harm

Event reporting
Transactional

Learning

Transformational

Redesign

Safer patient care

The Patient Safety Hand Book
Summary Of WHO/SEAR Regional
Workshop on Patient Safety

 Patient safety must be built into all

aspects of healthcare
 Patient safety is action-oriented
 Patient safety is a mindset and a behavior
 Patient safety requires a safe reporting
environment
 Patient safety requires a partnership with
patients, their families and communities
Clinicians involved in an adverse event
need...
 support
 advice
 recognition of
systems
 nature of adverse
events
 sense of security
about Investigation
& improvement
processes

Fallibility is part of the human condition

We can’t change the human condition
We can change the conditions under which people work
Medical error: NPSA – NHS, 2005

My mistake
Everyone makes mistakes. When patients are
harmed, all those involved – staff, families and
patients – can feel devastated.
It isn’t easy to be open and honest when
things go wrong. You may worry that you’ll
be blamed or that your career will suffer. But
the NHS can only learn how to prevent errors
if you speak up when you make a mistake.
Here, some of the most senior and influential
doctors from across the country share their
mistakes and the lessons they learned
from them.
 Medical error: NPSA – NHS, 2005
‘As I emptied the syringe, I
realised with horror that I’d
picked up the wrong one’

‘I made an incision over what I

Chairman, British Medical Association took to be a vein. As I hooked
the vessel, I realised that it was
the common peroneal nerve’

President, Royal College of Surgeons of England

‘I suddenly realised that I’d put in

far too much heparin’

Dean of Postgraduate Medical Studies, North Western Deanery

Patients who experience an adverse
event need..

 to know what happened

 advice about necessary treatment
 change to prevent recurrence
 ongoing support
 Siklus Kegiatan Keselamatan
Patient Pasien
1.
Involvement/ Pelaporan • Risk Grading
Communication Matrix
Insiden • Risk Analysis :
6. RCA,
2. FMEA
Implementasi &
“Measurement” Analisis/Belajar
RS Riset
yang lebih
5.
aman 3.
Pelatihan
Seminar Pengembangan
Solusi
4.
Panduan
Pedoman
Standar
@PERSI, 2006
“ Act as a Leader not a Manager,
Stop Managing Start Leading !”

( Robert Flater : “Jack Welch and GE Way” )

TERIMA KASIH

UTAMAKAN
KESELAMATAN PASIEN