Bs Membangun Budaya Keselamatan Pasien

8/10/2019 Bs Membangun Budaya Keselamatan Pasien

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MEMBANGUN BUDAYAMEMBANGUN BUDAYAKESELAMATAN PASIENKESELAMATAN PASIEN

BUDI SAMPURNABUDI SAMPURNA


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SISTEMATIKASISTEMATIKA

PendahuluanPendahuluan

Pengertian Budaya Keselamatan pasienPengertian Budaya Keselamatan pasien Manfaat Budaya Keselamatan pasienManfaat Budaya Keselamatan pasien

Survei Keselamatan PasienSurvei Keselamatan Pasien


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Medical servicesMedical services


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WHAT ARE THE HAZARDS

PROBABILITY, SEVERITY, AND EXPOSURE ?

LEVEL OF RISK ?

ACCEPTABLE ?

CAN IT BE ELIMINATED ?

CAN IT BE REDUCED ?

CANCEL THE MISSION

YES NO

ACCEPT THE RISK

ELIMINATE

REDUCED


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SUDAHKAH SUATU PROSEDUR BETUL-BETUL AMAN?ADAKAH POSSIBLE FAILURE MODE?


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KENALILAH PENYEBAB KECELAKAAN, BAIK DARISISI FAKTOR MANUSIA MAUPUN FAKTOR SISTEM


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MISHAP ANALYSISMISHAP ANALYSIS

MISHAP OCCURS

RISK UNACCEPTABLE RISK ACCEPTABLE

MANAGEMENT

FACTORS LTA

MISHAP

ACCEPTABLE

PREVENTION

METHODS

LTA

IMPLEMENTATION

PREVENTION

METHODS LTA

PREVENTION

POLICY LTA

IMPLEMENTATION

OF POLICY LTA

RISK ASSESSMENT

LTA

RISK PREVENTION

LTA

LTA = LESS THAN ADEQUATE


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BUDAYA SAFETYBUDAYA SAFETY

A safety culture is where staff within an

organisation have a constant and activeawareness of the potential for things to gowrong. Both the staff and the organisation are

able to acknowledge mistakes, learn from them,and take action to put things right.

Budaya keselamatan adalah dimana staf dalam suatu

organisasi memiliki kesadaran yg konstan dan aktiftentang hal yg potensial menimbulkan kesalahan.

Baik staf maupun organisasi mampu membicarakankesalahan, belajar dari kesalahan tsb, dan mengambiltindakan perbaikan


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Being open and fair means sharing information

openly and freely, and fair treatment for staffwhen an incident happens. This is vital for boththe safety of patients and the well-being of those

who provide their care.

Bersikap terbuka dan adil / jujur berarti membagi

informasi secara terbuka dan bebas, dan penangananadil bagi staf bila insiden terjadi.

Hal ini penting bagi keselamatan pasien dan

ketenangan bagi pemberi layanan


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The systems approach to safety acknowledges

that the causes of a patient safety incidentcannot simply be linked to the actions of theindividual healthcare staff involved. All incidents

are also linked to the system in which theindividuals were working.

Pendekatan sistem pada keselamatan menerangkanbahwa penyebab insiden keselamatan pasien tidakdapat dihubungkan dengan sederhana ke staf yangterlibat. Semua insiden berkaitan juga dengan sistemtempat orang itu bekerja


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Changing values, beliefs and attitudes is

not easy . Developing a safety culture in anorganisation needs strong leadership andcareful planning and monitoring.

Mengubah nilai-nilai, keyakinan, dan perilaku tidaklahmudah. Pengembangan budaya keselamatan dalamsuatu organisasi memerlukan kepemimpinan yang kuat

dan perencanaan & pemantauan yang cermat


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It is vital that not only clinical staff but all

those who work in organisations, as wellas patients and carers, ask themselveshow they can help to improve the safety ofpatients.

Perubahan nilai, keyakinan dan perilaku tersebutpenting bukan hanya bagi staf, melainkan juga semuaorang yang bekerja di rumah sakit tersebut, sertapasien dan keluarganya. Tanyakan apa yang bisamereka bantu untuk meningkatkan keselamatan pasien


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KOMPONENKOMPONEN

1) acknowledgment of the high risk, error1) acknowledgment of the high risk, error--

prone nature of an organization's activities,prone nature of an organization's activities, 2) blame2) blame--free environment wherefree environment where

individuals are able to report errors or closeindividuals are able to report errors or close

calls without punishment,calls without punishment, 3) expectation of collaboration across ranks3) expectation of collaboration across ranks

to seek solutions to vulnerabilities, andto seek solutions to vulnerabilities, and 4) willingness on the part of the4) willingness on the part of the

organization to direct resources to addressorganization to direct resources to address

safety concerns.safety concerns.

Penjelasan / pemahaman tentang aktivitasorganisasi yang bersifat risiko tinggi dan rentan

kesalahan

Lingkungan yang bebas-menyalahkan, sehingga

orang dapat melapor kesalahan tanpapenghukuman

Harapan kerjasama lintas tingkatan untuk mencarisolusi atas vulnerabilitas

Kemauan organisasi untuk mengarahkan sumberdaya untuk kepentingan keselamatan

AHRQ


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Components of a Culture of Safety

Commitment to safety articulated at the highest levels of the

organization and translated into shared values, beliefs, and

behavioral norms at all levels.

Necessary resources, incentives, and rewards provided by the

organization to allow this commitment to occur.

Safety is valued as the primary priority, even at the expense of

production or efficiency ; personnel are rewarded for erring on

the side of safety even if they turn out to be wrong.

Communication between workers and across organizational levelsis frequent and candid.

Unsafe acts are rare despite high levels of production.

There is an openness about errors and problems; they are reported

when they do occur. Organizational learning is valued; the response to a problem

focuses on improving system performance rather than on individual

blame.

Source: Singer SJ, Gaba DM, Geppert JJ, et al. The culture of safety: results of an organization-widesurvey in 15 California hospitals. Qual Saf Health Care 2003 Apr;12(2):112-8.Reproduced with permission from the BMJ Publishing Group.


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BLAMINGBLAMING vsvs SAFETYSAFETY

BLAMING:BLAMING:

ANALISIS BERAKHIR PADA HUMAN FACTORSANALISIS BERAKHIR PADA HUMAN FACTORS

TINDAKAN: MENYALAHKAN DAN MENGHUKUMTINDAKAN: MENYALAHKAN DAN MENGHUKUM

(LESS) REWARD AND (MORE) PUNISHMENT(LESS) REWARD AND (MORE) PUNISHMENT

SIKAP: SEMBUNYIKAN KESALAHANSIKAP: SEMBUNYIKAN KESALAHAN

SAFETY:SAFETY:

REPORTING, ANALYSIS, LEARNING,REPORTING, ANALYSIS, LEARNING,

(MORE) REWARD AND (LESS) PUNISHMENT(MORE) REWARD AND (LESS) PUNISHMENT TINDAKAN: CARI UPAYA PENCEGAHANTINDAKAN: CARI UPAYA PENCEGAHAN

SIKAP: BERLOMBA BERBUAT BAIK DANSIKAP: BERLOMBA BERBUAT BAIK DAN

MENCEGAH YG BURUK (BUDAYA BELAJAR)MENCEGAH YG BURUK (BUDAYA BELAJAR)


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BLAMING ?BLAMING ?


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SUPPORTING?SUPPORTING?


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SIKAP RUMAH SAKITSIKAP RUMAH SAKIT

Pastikan RS memiliki kebijakan ygmenjabarkan apa yg harus dilakukan staf

segera setelah terjadi insiden, bagaimanalangkah pengumpulan fakta harus dilakukan& dukungan apa yang harus diberikan

kepada staf, pasien - keluarga Pastikan RS memiliki kebijakan yg

menjabarkan peran & akuntabilitas individualbilamana ada insiden

Tumbuhkan budaya pelaporan & belajar dariinsiden yang terjadi di RS.

Lakukan asesmen dengan menggunakansurvei penilaian KP

KKP RS


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SIKAP STAF DALAM TIMSIKAP STAF DALAM TIM

Pastikan rekan sekerja anda merasa

mampu untuk berbicara mengenaikepedulian mereka & berani melaporkan

bilamana ada insiden

Demonstrasikan kepada tim anda ukuran

yang dipakai di RS anda utk memastikan

semua laporan dibuat secara terbuka &terjadi proses pembelajaran serta

pelaksanaan tindakan / solusi yg tepatKKP RS


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TERBUKA DAN JUJURTERBUKA DAN JUJUR

staff are open about incidents they have beeninvolved in;

staff and organisations are accountable for theiractions;

staff feel able to talk to their colleagues andsuperiors about any incident;

organisations are open with patients, the public

and staffwhen things have gone wrong, andexplain what lessons will be learned;

staff are treated fairly and supported when an

incident happens.NHS


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Being open and fair does notmean an absence of

accountability.

Accountability for patient safety means being openwith patients, explaining the actions taken and

providing assurance

that lessons will be learned.NHS


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TERBUKA DAN JUJURTERBUKA DAN JUJUR

SINGKIRKAN MITOSSINGKIRKAN MITOS--MITOS:MITOS:

the perfection myth:bila orang bekerja keras maka mereka tidakakan membuat errors

the punishment myth:

bila kita menghukum orang yang melakukan

errors maka akan semakin sedikit pembuaterrors, atau bahwa tindakan pendisiplinandapat memperbaiki melalui channelling atau

meningkatkan motivasi.NHS


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Penanganan InsidenPenanganan Insiden

Staff harus sama persepsinya tentangStaff harus sama persepsinya tentang

insideninsiden Staff harus tahu apa yang harus dilakukanStaff harus tahu apa yang harus dilakukan

bila menemui insiden: mencatat, melapor,bila menemui insiden: mencatat, melapor,dianalisis, memperoleh feeddianalisis, memperoleh feed--back, belajarback, belajar

dan mencegah pengulangandan mencegah pengulangan

Staff harus akuntabel dan tahu bagaimanaStaff harus akuntabel dan tahu bagaimanapendekatan sistem dan personilpendekatan sistem dan personil

SO O O O


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RESOLUTION OF ERRORRESOLUTION OF ERROR

NEGLECT / USED WRONG PROCEDURE

DID NOT KNOW

CORRECT

PROCEDURE

KNEW CORRECT

PROCEDURE

LACKED

EXPERIENCE

LACKED

INFORMATION

LACKED TRAINING

OR PRACTICE

LACKED

TRAINING

DELIBERATE

INTENTIONAL

TOLERATED

PRESSURES

LACKED

DISCIPLINE

PUNISHMENT

NEVER KNEW FORGOT

MANAGEMENT ACTION TO CORRECT THE SYSTEM


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MENGAPA BUDAYA SAFETY?MENGAPA BUDAYA SAFETY?

Bukti di industri lain menunjukkan bahwaBukti di industri lain menunjukkan bahwa

budaya organisasi yang berorientasi kebudaya organisasi yang berorientasi kekeselamatan dan sikap karyawan yangkeselamatan dan sikap karyawan yang

berani bicara tentang terjadinya kesalahanberani bicara tentang terjadinya kesalahan

telah meningkatkan keselamatantelah meningkatkan keselamatan

Di Rumah Sakit WimmeraDi Rumah Sakit Wimmera --Australia:Australia:

Penurunan Adverse EventsPenurunan Adverse Events Pd pasien rawat inap : 1,35%Pd pasien rawat inap : 1,35% -- 0,74%0,74%

Pd pasien IGD : 3,26%Pd pasien IGD : 3,26% -- 0,48%0,48%


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MANFAAT BUDAYA SAFETYMANFAAT BUDAYA SAFETY

a potential reduction in the recurrence and

in the severity of patient safety incidentsthrough increased reporting andorganisational learning;

Potensi mengurangi angka kejadian dankeparahan kejadian patient safety melalui

peningkatan pelaporan dan pembelajaranorganisasi


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a reduction in the physical and

psychological harm patients can sufferbecause people are more aware of patientsafety concepts, are working to prevent

errors and are speaking up when things gowrong;

Pengurangan derita fisik dan psikologis pasien,karena orang makin sadar tentang konseppatient safety akan bekerja mencegahkesalahan dan berbicara bila terjadi kesalahan


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a lower number of staff suffering from

distress, guilt, shame, loss of confidenceand loss of morale because fewerincidents are occurring;

Penurunan jumlah staf yang menderita

tertekan, merasa bersalah, malu, kehilanganpercaya diri, dan kehilangan keberanianmental, karena berkurangnya insiden yang

terjadi


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an improvement in waiting times fortreatment through a higher turnover of

patients. This is because patients whoexperience a safety incident require, on

average, an extra seven to eight days inhospital over and above the time theirtreatment would normally require ;Peningkatan turnover pasien, mengingatpasien yg terkena insiden umumnya

membutuhkan perawatan 7-8 hari lebih darimasa rawat normal


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a reduction in the costs incurred for

treatment and extra therapy; a reduction in resources required for

managing complaints and claims;

Pengurangan biaya untuk pengobatan /penatalaksanaan ekstra akibat insiden

Pengurangan kebutuhan sumber daya untukmenangani komplain dan klaim


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a decrease in wider financial and social

costs incurred through patient safetyincidents including lost work time anddisability benefits.

Penurunan biaya finansial dan sosial yangdiperlukan untuk menangani insiden patientsafety, termasuk kehilangan jam kerja danpembayaran kecacatan


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BAGAIMANA MEMULAIBAGAIMANA MEMULAIPENERAPAN BUDAYAPENERAPAN BUDAYA

KESELAMATAN PASIEN?KESELAMATAN PASIEN?


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MULAILAH DENGAN SURVEIMULAILAH DENGAN SURVEI

TENTANG ISUTENTANG ISU ::

Bagaimana kemampuan managemensenior melihat ke depan danberkomitmen ke arah keselamatan

Bagaimana komunikasi antara stafdengan manager


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TENTANG ISU:

Bagaimana sikap dan perilaku dalammelaporkan suatu kejadian, blaming danpenghukumannya

Bagaimana faktor-faktor dalam lingkungankerja mempengaruhi kinerja, seperti

kelelahan, pemecahan perhatian, desainperalatan dan ketersediaan/kesiapan alat.


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TOOLS UNTUK SURVEITOOLS UNTUK SURVEI

TYPOLOGY:TYPOLOGY: Checklist for Assessing Institutional Resilience (CAIR )

Manchester Patient Safety Assessment Tool20(MaPSaT)

Advancing Health in America (AHA) and Veterans

Health Association (VHA): Strategies for Leadership.An Organisational Approach to Patient Safety

DIMENSIONAL: Safety Attitudes Questionnaire (SAQ)

Stanford Patient Safety Centre of Inquiry Culture

Survey

contoh


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contoh


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I. Background VariablesI. Background Variables

A.A. What is your primary work area or unit in this hospital?What is your primary work area or unit in this hospital?

H1.H1. How long have you worked in thisHow long have you worked in this hospital?hospital?H2.H2. How long have you worked in your current hospitalHow long have you worked in your current hospital

work area/unit?work area/unit?

H3.H3. Typically, how manyTypically, how many hours per weekhours per week do you work indo you work inthis hospital?this hospital?

H4.H4. What is your staffWhat is your staff positionposition in this hospital?in this hospital?

H5.H5. In your staff position, do you typically have directIn your staff position, do you typically have directinteraction orinteraction or contact with patientscontact with patients??

H6.H6. How long have you worked in your current specialtyHow long have you worked in your current specialtyor profession?or profession?

Ocontoh


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II. Outcome measuresII. Outcome measures

Frequency of Event ReportingFrequency of Event Reporting

Overall Perceptions of SafetyOverall Perceptions of Safety

Patient Safety GradePatient Safety Grade

Number of Events ReportedNumber of Events Reported

contoh


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Overall Perceptions of Safety:Overall Perceptions of Safety: A15.A15. Patient safety is never sacrificed to getPatient safety is never sacrificed to get

moremore work done.work done. A18.A18. Our procedures and systems are goodOur procedures and systems are good

at preventing errors from happening.at preventing errors from happening. A10r.A10r. It is just by chance that more seriousIt is just by chance that more serious

mistakes donmistakes dont happen around here.t happen around here.(reverse worded)(reverse worded)

A17r.A17r. We have patient safety problems in thisWe have patient safety problems in this

unitunit (reverse worded)(reverse worded)

Reliability of this dimensionReliability of this dimensionCronbachCronbachss alpha (4 items) = .74alpha (4 items) = .74

Keselamatan pasien tidak pernah dikorbankan untukmemperbanyak pekerjaan yang bisa dikerjakan

Prosedur dan sistem kita adalah bagus dalam mencegahterjadinya kesalahan

Hanyalah suatu kebetulan bahwa kesalahan yang lebihserius tidak terjadi disini (neg)

Kita memiliki masalah keselamatan pasien di unit ini (neg)

IIIIII. Safety Culture DimensionsSafety Culture Dimensionscontoh


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III.III. Safety Culture DimensionsSafety Culture Dimensions

(Unit level)(Unit level) Supervisor/manager expectations & actionsSupervisor/manager expectations & actions

promoting safetypromoting safety Organizational LearningOrganizational LearningContinuousContinuous

improvementimprovement

Teamwork Within Hospital UnitsTeamwork Within Hospital Units Communication OpennessCommunication Openness

Feedback and Communication About ErrorFeedback and Communication About Error

NonpunitiveNonpunitive Response To ErrorResponse To Error StaffingStaffing

Hospital Management Support for PatientHospital Management Support for Patient

SafetySafety

Harapan dan tindakan supervisor dan manajer dalam

mempromosikan keselamatanPembelajaran organisasi perbaikan kontinyu

Kerjasama tim di RS

Keterbukaan dalam berkomunikasi

Umpan balik dan komunikasi tentang Kesalahan

Tanggapan yang tidak menghukum terhadap kesalahan

Staff

Manajemen RS mendukung Keselamatan Pasien

contoh


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Supervisor/manager expectations & actionsSupervisor/manager expectations & actions

promoting safetypromoting safety

B1.B1. My supervisor/manager says a good word whenMy supervisor/manager says a good word whenhe/she sees a job done according to establishedhe/she sees a job done according to establishedpatient safety procedures.patient safety procedures.

B2.B2. My supervisor/manager seriously considers staffMy supervisor/manager seriously considers staffsuggestions for improving patient safety.suggestions for improving patient safety.

B3r.B3r. Whenever pressure builds up, my supervisor/managerWhenever pressure builds up, my supervisor/managerwants us to work faster, even if it means takingwants us to work faster, even if it means takingshortcuts. (reverse worded)shortcuts. (reverse worded)

B4r.B4r. My supervisor/manager overlooks patient safetyMy supervisor/manager overlooks patient safety

problems that happen over and over. (reverseproblems that happen over and over. (reverseworded)worded)


Supervisor / Manajer:

Memuji bila staf melakukan prosedur PS

Mempertimbangkan usulan staf untuk peningkatan PS

Memerintahkan percepatan kerja dengan melakukan jalanpintas (neg)

Tidak memperhatikan masalah PS yg sudah terjadiberulang (neg)

contoh


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Teamwork Within Hospital UnitsTeamwork Within Hospital Units

A1.A1. People support one another in this unit.People support one another in this unit.

A3.A3. When a lot of work needs to be done quickly,When a lot of work needs to be done quickly,we work together as a team to get the workwe work together as a team to get the workdone.done.

A4.A4. In this unit, people treat each other withIn this unit, people treat each other withrespect.respect.

A11.A11. When one area in this unit gets really busy,When one area in this unit gets really busy,others help out.others help out.


Orang saling membantu di unit ini

Bila terdapat pekerjaan banyak yg membutuhkandiselesaikan secepatnya, kita bekerja bersama dalam satutim untuk menyelesaikannya

Dalam unit ini orang memperlakukan orang lain denganhormat

Bila salah satu area di unit ini sibuk, maka yang lain akan

membantunya

IV.IV. Safety Culture DimensionsSafety Culture Dimensionscontoh


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IV. Safety Culture Dimensionsy

(Hospital(Hospital--wide)wide) Teamwork Across Hospital UnitsTeamwork Across Hospital Units

Hospital Handoffs & TransitionsHospital Handoffs & Transitions

contoh


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Teamwork Across Hospital UnitsTeamwork Across Hospital Units

F4.F4. There is good cooperation among hospitalThere is good cooperation among hospital

units that need to work together.units that need to work together.F10.F10. Hospital units work well together to provideHospital units work well together to provide

the best care for patients.the best care for patients.

F2r.F2r. Hospital units do not coordinate well withHospital units do not coordinate well witheach other. (reverse worded)each other. (reverse worded)

F6r.F6r. It is often unpleasant to work with staff fromIt is often unpleasant to work with staff fromother hospital units. (reverse worded)other hospital units. (reverse worded)


Terdapat kerjasama yg baik antar unit yg

harus bekerjasamaUnit-unit bekerja bersama untuk memberilayanan terbaik kepada pasien

Unit-unit tidak bekerjasama satu sama lain(neg)

Sangat tidak menyebangkan bekerjadengan staf dari unit lain (neg)

MANFAAT SURVEIMANFAAT SURVEI


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MANFAAT SURVEIMANFAAT SURVEI

Suatu organisasi perlu mengetahuiSuatu organisasi perlu mengetahui

budayanya yg sekarang sebelum bisabudayanya yg sekarang sebelum bisamengubah budaya tersebutmengubah budaya tersebut

Mengubah sikap dan perilaku itu sulit danMengubah sikap dan perilaku itu sulit dan

lama, perlu pemahaman tentanglama, perlu pemahaman tentang

keselamatan pasien dan pendekatankeselamatan pasien dan pendekatan

sistem padasistem pada errorserrors dandan incidentsincidents Leadership penting dalam membentukLeadership penting dalam membentuk

valuevalue dandan beliefbelief dalam budayadalam budaya

LEVEL OF MATURITY WITH RESPECTLEVEL OF MATURITY WITH RESPECT

O S C


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TO A SAFETY CULTURETO A SAFETY CULTURE

Risk

management

Is an integral

Part of

Everything

That we do

Risk

management

Is an integral

Part of

Everything

That we do

We arealways

On alert forRisks that

Mightemerge

We areWe arealwaysalways

On alert forOn alert forRisks thatRisks that

MightMightemergeemerge

We havesystems in

Place toManage allLike risks

We havesystems inPlace to

Manage allLike risks

We doSomething

when weHave anincident

Why wasteour time

On safety?

Why wasteWhy wasteour timeour time

On safety?On safety?


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SELANJUTNYASELANJUTNYABAGAIMANA?BAGAIMANA?

LangkahLangkah langkahlangkah


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LangkahLangkah--langkahlangkah

1. Assess the culture of safety.

2. Provide science-of-safety education.3. Identify safety concerns.

4. Establish senior leader partnerships withunits.

5. Learn from one defect per month.

6. Re-assess (re-measure) the culture ofsafety.

Membangun budaya adalah suatu siklus yg tak henti-henti

ACTION RECOMMENDATIONS


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Seek leadership support for the creation of aculture of safety throughout the organization.

Support can be gained by providing datademonstrating that communication problems aremajor causes of medical errors and information onhow teamwork failures lead to malpractice claimsand by sharing success stories of facilities that

have affected patient safety by improving safetyculture.



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Partner with clinicians and managers in conducting

an assessment of the existing safety climate in theorganization. Appoint a project team, accountableto a senior executive, to carry out the assessment

using surveys, interviews, or other techniques.

Based on survey findings, formulate and execute

an action plan to improve the culture of safety.Establish realistic measures to gauge theeffectiveness of action plans.



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Provide safety science education tofrontline staff, managers, and physicians.Include teamwork training and educationin communication techniques.

Incorporate safety culture initiatives intothe overall organizational patient safetyplan. Ensure that patient safety initiatives,

action plans, and results of interventionsto improve safety are periodically reportedto the board of directors.



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Establish a nonpunitive system for reportingerrors, events, and near misses. Consider

implementing a reward-based reporting system,and ensure timely feedback to staff on howreports are used to improve patient safety.

Ensure that disclosure policies are in keeping

with current regulations and standards. Worktoward using disclosure with apology as a claim-avoidance strategy.



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Share information on improvements and

successes based on safety culturechanges to maintain enthusiasm forparticipation and support. Communicate

plans to address areas still in need ofimprovement and other opportunities to

enhance patient safety.

PengalamanPengalaman VHAVHA


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PengalamanPengalaman VHAVHA

The Veterans Health Administration (VHA) hasThe Veterans Health Administration (VHA) hasimplemented a multifaceted safety initiative,implemented a multifaceted safety initiative,

which was designed to build a culture of safetywhich was designed to build a culture of safetyand address system failures.and address system failures.

The approach consists of 4 major elements:The approach consists of 4 major elements: 1) partnering with other safety1) partnering with other safety--related organizationsrelated organizations

and affiliates to demonstrate a public commitment byand affiliates to demonstrate a public commitment byleadership,leadership,

2) establishing centers to direct safety efforts,2) establishing centers to direct safety efforts, 3) improving reporting systems, and3) improving reporting systems, and

4) providing incentives to health care team members4) providing incentives to health care team members

and division leaders. These tactics are detailed belowand division leaders. These tactics are detailed below

PengalamanPengalaman SMUHSMUH


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ggSouth Manchester University HospitalSouth Manchester University Hospital

Membangun sistem pelaporan insidenMembangun sistem pelaporan insiden

yang berbasis web bagi ujung tombakyang berbasis web bagi ujung tombak Bila laporan dimasukkan, sistem langsungBila laporan dimasukkan, sistem langsung

mengirim email ke Manajemenmengirim email ke Manajemen RS merawat inap 69.000 pasien/tahunRS merawat inap 69.000 pasien/tahun

Expected AE: 7.000 / tahunExpected AE: 7.000 / tahun

Setelah 3 tahun sistem dibangun, laporanSetelah 3 tahun sistem dibangun, laporansudah mencapai 4.500 / tahunsudah mencapai 4.500 / tahun

33--7% anonim, dirangsang utk pakai nama7% anonim, dirangsang utk pakai nama

PengalamanPengalaman SMUHSMUH


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gSouth Manchester University HospitalSouth Manchester University Hospital

Penjelasan tentang hubungan antaraPenjelasan tentang hubungan antara

Pelaporan dengan PendisiplinanPelaporan dengan Pendisiplinan Penjelasan tentang hubungan antaraPenjelasan tentang hubungan antara

Pelaporan dan pembelajaranPelaporan dan pembelajaran

Pelatihan dilakukan di tempatPelatihan dilakukan di tempat

Informasi dalam web: clinical risk, medicalInformasi dalam web: clinical risk, medical

alert, archived safety materials, patientalert, archived safety materials, patientsafety newslettersafety newsletter

OSF St. Joseph Medical Center,OSF St. Joseph Medical Center,


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in Bloomington, Ill.in Bloomington, Ill. Membolehkan juga pelaporan bersifatMembolehkan juga pelaporan bersifat

informal oleh staf keperawatan, ahliinformal oleh staf keperawatan, ahlifarmasi, laboratorium dll, melalui:farmasi, laboratorium dll, melalui:

Briefing saat pergantian shift jagaBriefing saat pergantian shift jaga Ronde rutin oleh manajemenRonde rutin oleh manajemen

Telepon hotlineTelepon hotline

Krause et alKrause et al


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Krause et alKrause et al

Di luar bidang kedokteran:Di luar bidang kedokteran:

safety assessments,safety assessments, steering committee formation,steering committee formation,

development of checklists of welldevelopment of checklists of well--specifiedspecifiedcritical behaviors related to safetycritical behaviors related to safety

observer training regarding the criticalobserver training regarding the critical

behaviors,behaviors,

observation and feedbackobservation and feedback

FAKTAFAKTA


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FAKTAFAKTA

Dengan sistem patient Safety, Sentara Norfolk GeneralDengan sistem patient Safety, Sentara Norfolk GeneralHospital: 84 % pengurangan Pneumonia yg berkaitan dgHospital: 84 % pengurangan Pneumonia yg berkaitan dg

ventilator dari 2001 s/d Juni 2004ventilator dari 2001 s/d Juni 2004 Dengan Tim Tanggap Cepat di Missouri Baptist MedicalDengan Tim Tanggap Cepat di Missouri Baptist Medical

Center telah menurunkan 60 % penurunan panggilanCenter telah menurunkan 60 % penurunan panggilandarurat henti nafas dan krisis serupa dan penurunandarurat henti nafas dan krisis serupa dan penurunan

15% henti jantung.15% henti jantung. Johns Hopkins Hospital mengalami peningkatan 49Johns Hopkins Hospital mengalami peningkatan 49 -- 9191

% proporsi pelaporan staf ICU tentang iklim safety dan% proporsi pelaporan staf ICU tentang iklim safety dan

menghilangkan kasus infeksi pembuluh darah akibatmenghilangkan kasus infeksi pembuluh darah akibatkateterisasi, mencegah 8 kematian dan berhemat $2 jutakateterisasi, mencegah 8 kematian dan berhemat $2 jutapertahun.pertahun.

Kasus adverse drug events menurun 91 percent di OSFKasus adverse drug events menurun 91 percent di OSFSt. Joseph Medical Center.St. Joseph Medical Center.

KATA AKHIRKATA AKHIR


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KATA AKHIRKATA AKHIR

Keselamatan Pasien di Rumah SakitKeselamatan Pasien di Rumah Sakithanya dapat dicapai dengan membangunhanya dapat dicapai dengan membangunbudaya yang berorientasikan kepadabudaya yang berorientasikan kepadakeselamatan pasienkeselamatan pasien

Budaya keselamatan pasien harusBudaya keselamatan pasien harusdipahami, dihayati dan diamalkan olehdipahami, dihayati dan diamalkan olehseluruh unsur rumah sakitseluruh unsur rumah sakit

Peran pimpinan, baik formil maupun nonPeran pimpinan, baik formil maupun nonformil diperlukan dalam membentukformil diperlukan dalam membentuk nilainilai

dan memberi teladan.dan memberi teladan.

Bs Membangun Budaya Keselamatan Pasien

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