MEMBANGUN BUDAYA
KESELAMATAN PASIEN
Keselamatan Pasien Dalam
UU. No 44 th 2009 Tentang Rumah Sakit
Tim:
• Anggota mampu berbicara, peduli & berani lapor bila ada insiden
• Laporan terbuka & terjadi proses pembelajaran serta pelaksanaan tindakan
/ solusi yg tepat.
BUDAYA ORGANISASI
Insiden
Risk tinggi
&medium
Laporan
(Seven steps to patient safety, An overview guide for NHS staff. Second print April 2004)
Improvements in Safety Performance
Technology
Numbers of Incidents
• Engineering ( teknik )
• Equipment
• Safety
• Compliance ( pemenuhan )
Time
Improvements in HSE Performance
Technology
Systems
Numbers of Incidents
• Engineering
• Equipment
• Safety
• Compliance
• Integrating HSE
• Certification
• Competence
• Risk Assessment
Time
Improvements in Safety Performance
Technology
Systems
Numbers of Incidents
• Behaviours
• Engineering • Leadership
• Equipment • Accountability
• Safety • Attitudes
• Compliance • HSE as a profit centre
Time
Basic principle of Patient Safety
1. Limiting Blame
Minimalisir hukuman/mempermalukan
(No Blame and Shame Game)
2. Awareness
Kesadaran akan besarnya potensi timbulnya medical error di RS
3. Transparency and Learning
Berbagi informasi secara terbuka dan bebas ,
dan berlaku adil saat terjadi kesalahan
(being open and Fair)
4. Systems Thinking Approach
pendekatan berfikir kesisteman
5. Accountability for Delivering Effective, Safe Care
What is a safety culture?
1.Kesadaran ( awareness ) yang aktif dan konstan
tentang adanya potensi timbulnya kesalahan.
Staf dan organisasi mampu mengenali kesalahan-
kesalahan,belajar dari kesalahan tsb,dan mengambil
tindakan untuk memperbaikinya
Causal Factors
Timing ( waktu )
Consequences (konsekuensinya )
Mitigating Factors ( keberuntungan )
UNINTENDED
LAPSES MEMORY FAILURE
(Penyimpangan )
INTENDED
(Disengaja )
ROUTINE
VIOLATIONS OPTIMISING
(pelanggaran )
NECESSARY/
SITUATIONAL
Human Error :
Top 10 Traps
1.Time pressure (Tekanan waktu)
2. Distracted environment (Lingkungan
terganggu)
3. High workload (tingginya beban kerja)
4. First-time evolution (evolusi pertama
kali)
5. First working day after days off (hari
pertama sesudah libur)
Human Error Top 10
Traps (cont)
6. One half hour after wake up or meal (satu
setengah jam sesudah makan)
7. Vague or incorrect guidance (bimbingan
salah atau samar-samar)
8. Overconfidence inducers (terlalu percaya
diri)
9. Imprecise communications (komunikasi
tak tepat)
10. Work stress (stres kerja)
Faktor Kontribusi
•
(Contributory factors):
Error
Producing Error
Management Conditions
Decisions/
Organisational
Processes Violation
Producing Violation
Conditions (pelanggaran )
3. Dampak (Consequences):
6.
Mengubah nilai-nilai, keyakinan, dan perilaku
tidaklah mudah.
TERIMA KASIH