8/16/2019 Formulir Laporan Insiden Kesalahan Pemberian Obat

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Formulir Laporan Insiden Kesalahan PemberianObat di RSUD DR.M.YUNUS BN!KULU

RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAXIMAL 2 x 24 JAM

L"POR"N INSIDN

(INTERNAL)

I. D"#" P"SIN

Nama: ....................................................................................................

.....

No MR : ......................................... Ruan$an: .............................................

Um! " : #$% &' * % &' + % -

* % - + - * - + % -

* % - + /# - * /# - + 0 -

* 0 -

 J13 1'm : L$' P1!1m5

P1666 &7 531 :P!&8 BPJSP1!3-"

 T66' M3 RS : ............................................................................ Jm .....................................

II. RIN%I"N K&"DI"N%. T66' 8 9 I381

 T66' : ........................................................................................ Jm ......................................

2.

I381 : ..........................................................................................................................................

/. K!'63 I381..............................................................................................................................................................................................................................................................................................................

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4. J13 I381" :

K13'- O!6

  Nm P31 76 1!'3 8 !1315 : ......................................................NMR : .......................

  Nm P31 76 m11!m & : ......................................................NMR : .......................

K13'- D33

  D33 O& 76 1!'3 8 !1315 : ...........................................

  D33 O& 76 8&1! : ...........................................

K13'- Jm'-

  Jm'- O& 76 1!'3 8 !1315 : ..........................................

  Jm'- O& 76 8&1! : ..........................................

K13'- J13

  J13 O& 76 1!'3 8 !1315 : ..............................................

  J13 O& 76 8&1! : ..............................................

. O!6 P1!m Y6 M1'5! I381"

K!7; : D1! < P1!; < P163 '7

P31

K1'!6 < P18m56 531

P16=6

L$' .............................................................................................................'sebut(an)

0. I381 1!=8 58" :

P31

L$' .............................................................................................................'sebut(an)

M3 : !7; < P16=6 < P18m56 < K1'!6 531, '5! 1 K/RS.

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>. I381 m176 531 :

P31 !; 5

P31 !; ='

P31 U?DL$' .............................................................................................................'sebut(an)

*. #empat Insiden

L31=8 ...................................................................................................'sebut(an)

(T1m5 531 &1!8)

@. Insiden ter+adi pada pasien , 'sesuai (asus pen-a(it spesialisasi)

P17 D'm 8 S&3513'337

A 8 S&3513'337

B18- 8 S&3513'337

O&31! ?71'6 8 S&3513'337

 THT 8 S&3513'337

M 8 S&3513'337

S! 8 S&3513'337

A313 8 S&3513'337

K' K1'm 8 S&3513'337

 J6 8 S&3513'337

P! 8 S&3513'337

 J; 8 S&3513'337

L$' ...........................................................................................................'sebut(an)

/0. Unit Departemen ter(ait -an$ men-ebab(an insiden

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U 1!=5171&& ...........................................................................................'sebut(an)

//. "(ibat Insiden #erhadap Pasien1 ,

K1m

C181! I!!11!3&1' < C181! B1!

C181! R11!3&1' < C181! S186

C181! R6

 T8 8 181!

/2. #inda(an -an$ dila(u(an se$era setelah (e+adian3 dan hasiln-a ,

...........................................................................................................................

...........................

...........................................................................................................................

...........................

...........................................................................................................................

...........................

/4. #inda(an dila(u(an oleh1 ,

 Tm : 1!8!8! : ..................................................................................................................

D1!

P1!;

P163'7 ......................................................................................................................

/5. "pa(ah (e+adian -an$ sama pernah ter+adi di Unit Ker+a lain61

 Y  T8

A5&' 7, 3 &6 8&;- .

Kapan 6 dan Lan$(ah tinda(an apa -an$ telah diambil pada Unit(er+a tersebut

untu( men7e$ah terulan$n-a (e+adian -an$ sama6

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P1m& L5!: ...............................

....

P11!m L5!: ...............................

....

P! : ...................................

P! : ...................................

 T6' L5!: ...................................

 T6' 1!m: ...................................

NB. " 5'- 3 =;&