Komite Nasional Keselamatan Pasien Rumah Sakit

Perkembangan Terkini
Keselamatan Pasien dan
Tantangan yang Dihadapi
 Tedjo Wahyu Putranto dr MM
• Komite Nasional Keselamatan Pasien di Rumah Sakit
• PERSI Kompartemen IKPRS
• KARS Survior & Pembimbing
• IRSJAM
 POKOK BAHASAN

 Definisi dan Konsep ICPS, International Classification for

Patient Safety

 WHO Patient Safety Programme of Work

 Patient Safety Future Directions & Challenges

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Conceptual Framework
for the International
Classification for
Patient Safety
Version 1.1
WHO
International
Classification
For Patient Safety,
-ICPS- 2009

1. Incident Type
2. Patient Outcomes
3. Patient Characteristics
4. Incident Characteristics
5. Contributing
Factors/Hazards
6. Organizational Outcomes
7. Detection
8. Mitigating Factors
9. Ameliorating Actions
10. Actions Taken to Reduce
Risk
 TIPE INSIDEN
1. Administrasi Klinis
2. Proses / Prosedur Klinis
3. Dokumentasi
4. Infeksi terkait Pelayanan Kesehatan
5. Medikasi / Cairan IV
6. Darah / Produk Darah
7. Nutrisi
Tipe Insiden 8. Oxigen / Gas / Uap
9. Alat / Perlengkapan Medis
10. Perilaku
11. Jatuh
12. Kecelakaan Pasien
13. Infrastruktur / Bangunan / Peralatan tetap
14. Sumber2 / Manajemen Organisasi
15. Laboratorium
Keselamatan Pasien Rumah Sakit - KPRS
• Suatu sistem dimana RS membuat asuhan pasien
lebih aman.
• Hal ini termasuk: *asesmen risiko, *identifikasi &
pengelolaan hal yg berhubungan dgn risiko pasien,
*pelaporan & analisis insiden, *kemampuan belajar
dari insiden & tindak lanjutnya serta *implementasi
solusi untuk meminimalkan timbulnya risiko.
(KKP-RS)

(Penjelasan UU 44/2009 ttg RS pasal 43)

Patient safety incident: an event or circumstance which could have resulted, or did
result, in unnecessary harm to a patient.
Adverse Event : an incident which results in harm to a patient.
Near Miss : An incident that did not cause harm. (WHO)

Insiden Keselamatan Pasien (IKP) (Patient Safety Incident)

Setiap kejadian atau situasi yg dpt mengakibatkan / berpotensi mngakibatkan harm
(penyakit, cedera, cacad, kematian dll) yg tdk seharusnya terjadi.
KejadianTidak Diharapkan (KTD) (Adverse event)
Suatu kejadian yg mengakibatkan cedera yg tdk diharapkan pada pasien krn
suatu tindakan (“commission”) atau krn tdk bertindak (“omission”), bukan
krn “underlying disease” atau kondisi pasien.
Kejadian Nyaris Cedera (KNC) (Near miss)
Suatu kesalahan akibat melaksanakan suatu tindakan (commission) atau tdk
mengambil tindakan yg seharusnya diambil (omission), yg dpt mencederai
pasien, tetapi cedera serius tdk terjadi, 1). Dapat obat “c.i.”, tidak timbul
(chance), 2). Dosis lethal akan diberikan, diketahui, dibatalkan (prevention),
3). Dapat obat “c.i.”/dosis lethal, diketahui, diberi antidote-nya (mitigation).
(KKP-RS)
 Insiden Keselamatan Pasien
1. Kejadian Sentinel : KTD yg mengakibatkan kematian atau cedera
Juni 2010
yg serius
2. KTD (Kejadian Tidak Diharapkan) – Adverse event : insiden yang
mengakibatkan pasien cedera
3. KNC (Kejadian Nyaris Cedera ) – Near miss, Close call :
terjadinya insiden yg belum sampai terpapar ke pasien ( pasien
tidak cedera)
4. KTC (Kejadian Tidak Cedera) – No harm incident : insiden sudah
terpapar ke pasien, tetapi pasien tidak timbul cedera
5. KPC (Kondisi Potensial Cedera) – Reportable circumstance:
kondisi / situasi yang sangat berpotensi untuk menimbulkan
cedera, tetapi belum terjadi insiden. Contoh :Alat defibrilator yg
standby di IGD, tetapi kmd diketahui rusak ; ICU yg under staff
Permenkes 1691 / VIII / 2011
Figure 1: Venn diagram representing Institute of Medicine terminology

All episodes of care

All Errors
All Adverse Events

Preventable (Adverse Events

(Near Non Error)
Miss) Adverse Events
(Unpreventable
AE)
Negligent
Adverse Events

Gray,A :Adverse events and the National Health Service, an economic persp
report to the National Patient Safety Agency , November 2003
 Insiden Keselamatan Pasien
Kejadian Tidak Diharapkan (KTD)

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r f
p e a
sa p
d i e , …
v e r t ic –40.
n e r a c
il l l p 01;322 :1236
s w i c a
r or e d MJ 20
Er m Edit or ial:B

(Stevens–Johnson
Syndrome) (….…tertinggal……….??!!)
Regulatory Framework
1. Undang-Undang No. 44 Tahun 2009 tentang Rumah
Sakit
2. Undang-undang No. 36 Tahun 2009 tentang Kesehatan
3. Undang-undang No. 29 Tahun 2004 tentang Praktik
Kedokteran
4. Peraturan Menteri Kesehatan No.
1691/MENKES/PER/VIII/2011 Tentang Keselamatan
Pasien Rumah Sakit
5. Peraturan Menteri Kesehatan No.
251/MENKES/SK/VII/2012 Tentang Komite Keselamatan
Pasien Rumah Sakit
6. Keputusan HK.02.02 / MENKES/ 535/ 2016 Ttg Komite
Nasional Keselamatan Pasien Rumah Sakit
 Pencanangan
Gerakan Keselamatan Pasien Rumah Sakit
Di Indonesia, 21 Agustus 2005
 WHO, World Alliance for Patient Safety
PROGRAMME OF WORK (2005 )
Action areas :
1. Global Patient Safety Challenge :
1st Challenge, 2005 : Clean Care is Safer Care,
2nd Challenge, 2007-2008 : Safe Surgery Saves Lives
3rd Challenge, 2010 : Tackling Antimicrobial Resistance
2. Patients for Patient Safety
3. Research for Patient Safety
4. The International Classification for Patient Safety
5. Reporting and Learning Patient Safety
6. Solutions for Patient Safety
7. High 5s
8. Technology for Patient safety
9. Knowledge Management on Patient safety
10. Eliminate central line-associated bloodstream infections
11. Education for Safer Care
12. The Safety Prize
13. Medical Checklist : Pandemic H1N1 Cinical Checklist, Safe Childbirth Checklist ,
Trauma Care Checklist

(WHO : World Alliance for Patient Safety, Forward Programme, 2008-2009)

WHO South East Asia Regional Patient Safety Workshop on “ Patients for
Patient Safety”
Jakarta, 17 – 19 July 2007
- P4PS -

• Negara peserta (10) : Bangladesh, Bhutan, India, Indonesia,

Maldives, Myanmar, Nepal, Sri Lanka, Thailand, Timor-Leste. Juga
Pakar2 WHO dari Patients for Patient Safety.
• Indonesia : Dr Sutoto, Dr Gunawan, Dr Nico Lumenta, Dr Marius
Widjajarta, Dr Purnamawati, Paula Dewi, Ermiel Thabrani, KKI Dr
Hardi Yusa, PERSI Dr Adib Yahya, PPNI, Arsada Dr Yvonne
• Peserta adalah Patient Safety Stake Holder : Patients, NGO
Advocates, Medical Council, Medical Association, Nurse
Association, Policy makers
• Topik : Building partnerships, Ongoing work in the region,
Patients & Consumer voices, Regional priorities & challenges,
Action planning.
•  Jakarta Declaration
Regional Patient Safety Workshop on “ Patients for Patient Safety”
Jakarta, 17 – 19 July 2007
Wakil Indonesia terpilih sebagai
: Chairman, WHO SEAR
Patient Safety Workshop on “
Patients for Patient Safety”
 WHO SEAR Patient Safety Workshop on
“ Patients for Patient Safety”

Jakarta Declaration 

Jakarta, 19 July 2007

 KERANGKA KERJA KOMPREHENSIF KESELAMATAN PASIEN.

Hosp Risk Mgt

Clinical Risk Mgt

Risiko KTD, KNC Risiko

3.
1. Upaya Umum Upaya Khusus 2.
 Pelaporan
(Klasik) (Baru)
IKP
Keselamatan Keselamatan
 Diagnostik
Pasien Pasien
 Solusi

4.
Taksonomi Keselamatan Pasien
Definisi, Sistematika, Klasifikasi
 Upaya Umum (Klasik) Keselamatan Pasien 1.
*Organisasi/Manajemen
1. Standar Yan RS, Standar Profesi
2. Good Professional Practice, EB Practice
3. Good Corporate Governance, Komite Etik RS
4. Good Clinical Governance, Komite Medis, Komite Etik,
Medical Audit, Clinical Indicator, Credentialling, EBM
5. Konsep & Evaluasi Mutu : QA, TQM, PDCA, Akreditasi, ISO
6. Sistem Rekam Medis, Informed consent
7. …dsb…

*Pelayanan
8. Pengendalian Infeksi Nosokomial
9. Safe blood transfusion
10.Yan Peristi
11.Hospital Pharmacy, Penggunaan obat rasional
12.Yan Laboratorium, Radiologi (D/, Th/), Penunjang Medis
lain
13.….dsb….
 Upaya Khusus (Baru) Keselamatan Pasien
* 7 LANGKAH MENUJU KESELAMATAN PASIEN RUMAH SAKIT
1. Bangun kesadaran akan nilai Keselamatan Pasien, 2. Pimpin dan dukung staf
2.
anda, 3. Integrasikan aktivitas risiko, 4. Kembangkan sistem pelaporan, 5. Libatkan
dan berkomunikasi dengan pasien, 6. Belajar dan berbagi pengalaman tentang KP,
7. Cegah cedera melalui implementasi sistem KP

* 7 STANDAR KESELAMATAN PASIEN RS & AKREDITASI YAN KPRS

I. Hak pasien, II. Mendidik pasien dan keluarga, III. Keselamatan pasien dan
Asuhan Berkesinambungan, IV. Penggunaan metoda peningkatan kinerja, utk
melakukan evaluasi & meningkatkan KP, V. Peran kepemimpinan dalam
meningkatkan KP, VI. Mendidik staf tentang KP, VII.Komunikasi merupakan kunci
bagi staf untuk mencapai KP

* WHO – PATIENT SAFETY – 13 ACTION AREAS

1)Global Patient Safety Challenge, 2)Patients for PS, 3)Research for PS,
4)International, Classification for PS, 5)Reporting and Learning PS, 6)Solutions for
PS, 7)High 5s, 8)Technology for PS, 9)Knowledge Management on PS,
10)Eliminate central line-associated bloodstream infections, 11)Education for
Safer Care, 12)The Safety Prize, 13) Medical Checklist

* 6 SASARAN KESELAMATAN PASIEN RUMAH SAKIT

 Upaya Diagnostik &
Solusi
Patient 1. 3. •Risk Grading Matrix
•Risk Analysis : RCA,
Involvement/ Pelaporan
Communication IKP FMEA

6.
Implementasi & 2.
“Measurement” Analisis/Belajar
KTD Riset
Yan RS
5. yang lebih
Pelatihan aman 3.
Seminar
Pengembangan
4. Solusi
Panduan
Pedoman
Standar
 4.

Taksonomi Keselamatan Pasien

Definisi, Sistematika, Klasifikasi
 Why Patient Safety and Quality Of Care

 1 in 10 patients harmed in hospital care

 14 out of every 100 patients affected by HAI
 2% patients subject to surgical complications
for the 234 million surgical operations
performed every year
 6.3 events per patient days in the US
annually due to medical devices
 20-40% health spending wasted due to poor
quality of care and safety failures

(Dhingra-Kumar, N, Global Overview on Patient Safety and Quality Improvement,

Patient Safety and Quality Improvement WHO-HQ, 2016)
(Dhingra-Kumar, N, Global Overview on Patient Safety and Quality Improvement,
Patient Safety and Quality Improvement WHO-HQ, 2016)
(Dhingra-Kumar, N, Global Overview on Patient Safety and Quality Improvement,
Patient Safety and Quality Improvement WHO-HQ, 2016)
(Dhingra-Kumar, N, Global Overview on Patient Safety and Quality Improvement,
Patient Safety and Quality Improvement WHO-HQ, 2016)
 Conceptual framework for integrated
people-centred health services (2015)
IPCHS

(WHO global strategy on integrated people-centred2014

health services 2016-2026, July 2015)
(Dhingra-Kumar, N, Global Overview on Patient Safety and Quality Improvement,
Patient Safety and Quality Improvement WHO-HQ, 2016)
 • The NIHR Imperial
Patient Safety
Translational Research
Centre (PSTRC)
• is part of the National
Institute for Health
Research and
• is a collaboration
between Imperial
College London and
• Imperial College
Healthcare NHS Trust

(Yu A, Flott K, Chainani N, Fontana G, Darzi A. Patient Safety 2030. London, UK: NIHR
Imperial Patient Safety Translational Research Centre, 2016.)
 SAFETY

 Just Culture
 Reporting Culture
 Learning Culture
 Informed Culture
 Flexible Culture
 Generative Culture (MaPSaF)
 7 Standar KP
 6 SKP
 7 Langkah KPRS
 13 Program WHO-PS
 The Just Culture Model (simplified)

Human At-Risk Reckless

Error Behavior Behavior

Product of Our Current A Choice: Risk Believed Conscious Disregard of

System Design and Behavioral Insignificant or Justified Substantial and Unjustifiable
Choices Risk

Manage through changes in: Manage through: Manage through:

• Choices • Removing incentives for • Remedial action

• Processes at-risk behaviors • Punitive action
• Procedures • Creating incentives for
• Training healthy behaviors
• Design • Increasing situational
• Environment awareness

Console Coach Punish

Dukungan Pelatihan Sanksi
Disiplin
© 2012
 Manchester Patient Safety Framework – MaPSaF
Levels of maturity with respect E. Risk
to a safety culture management
(Kita sudah punya is an integral
(Tingkat kematangan dalam part of
sistem utk
budaya keselamatan) D. We are everything
mengelola risiko yg
teridentifikasi) always on that we do
the alert for
(Kita berbuat risks that
(Mengapa sesuatu bila C. We have might (Manajemen risiko
membuang waktu terjadi insiden) systems in emerge merupakan bagian
utk keselamatan) place to integral dari semua
B. We do manage all (Kita selalu kegiatan yg kita
A. Why something identified waspada thd risiko kerjakan)
waste our when we risks yg mungkin timbul)
time on have an
safety? incident
PATHOLOGICAL REACTIVE BUREAUCRATIC PROACTIVE GENERATIVE
 “The world is a dangerous
place to live; not because of
the people who are evil, but
because of the people who
don't do anything about it.“
(Albert Einstein)
Terima Kasih