Seminar Nasional VII PERSI20 – 23 Agustus 2005

SUATU TANTANGAN BAGI PELAYANAN RUMAH SAKITSUATU TANTANGAN BAGI PELAYANAN RUMAH SAKIT

Komite Keselamatan Pasien Rumah SakitKKP-RSP E R S I

Dr. Nico A. Lumenta, K.Nefro, MM

Pendahuluan Glossary Dasar : Mengapa Patient Safety Perkembangan Patient Safety di dunia Contoh Produk : Program, National Goals, Standar, Pedoman / Panduan, Pelaporan Kesimpulan Komite Keselamatan Pasien – Rumah Sakit Kesimpulan

Patient Safety adalah isu terkini, besar, penting, dalam Pelayanan Rumah Sakit, praktis belum lama, dimulai sejak th 2000an Menteri Kesehatan mencanangkan Gerakan Moral Keselamatan Pasien pada Seminar Nasional VII PERSI 21 Agustus 2005 Dalam jangka panjang “tepat” utk kondisi di Indonesia dgn maraknya tuduhan “Malpraktek” ( bias?) RS perlu melaksanakan Image Building meningkatkan kepercayaan masyarakat Telah dibentuk KOMITE KESELAMATAN PASIEN RUMAH SAKIT KOMITE KESELAMATAN PASIEN RUMAH SAKIT (KKP-RS)(KKP-RS) – PERSI, pd tgl 1 Juni 2005 : Dalam tahap membangun “Awareness” RS, Unit Yan Kes, Org. Profesi, akan Keselamatan Pasien KP sdh dipresentasi ke Menteri Kesehatan, DirJen Bina YanMed, KaDinasKes DKI Jkt, dipaparkan pd pertemuan nasional : Raker MAKERSI Juli di Semarang, di Rakernas PELKESI Agustus di Tomohon Keselamatan Pasien selain masih dalam kerangka Peningkatan Mutu, juga merupakan pendekatan “Green Product” oleh Rumah Sakit ke masyarakat

Rumah SakitRumah Sakit

1) Padat Modal2) Padat Teknologi 3) Padat Karya 4) Padat Profesi *!*5) Padat Sistem 6) Padat Mutu7) Padat Risiko8) Padat Keluhan/Masalah9) Padat “Error “ ?10) RS = “Kompleks yg padat”

Beberapa ciri penting RS

Pabrik Toko/Mal Rumah Proses Produksi Distribusi Transaksi Konsumsi

Bahan Produk Barang

KK KK

Produk Jasa / Yan RS

Proses Produksi Produk Jasa (Distribusi) Transaksi Konsumsi

K KK K K K

“ Produk Barang - Jasa”

Konsumen : - Kehadiran AZ- Keterlibatan tinggi : pasien = materi produk- Mengalami 3 elemen pokok

Produk Barang

EBMEBM

  MUTUMUTUETIKETIK

Isu makro rumah sakit :(3)

SAFE-SAFE-TYTY

Safety hadirsendiri/explisit,tetap terkaitdgn Mutu

“Safety is a fundamental principle of patient care and a critical componentof quality management.” (World Alliance for Patient Safety, Forward Programme, WHO, 2004)

Patient safetyThe prevention of harm caused by errors of commission and omission. (IOM)

Patient safetyThe process by which an organisation makes patient care safer. This should involve: risk assessment; the identification and management of patient-related risks; the reporting and analysis of incidents; and the capacity to learn from and follow-up on incidents and implement solutions to minimise the risk of them recurring. (NHS-NPSA)Patient safety incidentAny unintended or unexpected incident which could have or did lead to harm for one or more patients. (NHS-NPSA)

Medical errors Mistakes made in the process of care that result in or have the potential to result in harm to patients. Mistakes include the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Can be the result of an action that is taken (error of commission) or an action that is not taken (error of omission).

Medical error An adverse event or near miss that is preventable with the current state of medical knowledge. (QuIC)

Adverse eventAn event that results in unintended harm to the patient by an act of commission or omission rather than by the underlying disease or condition of the patient. (IOM)Adverse eventAn injury that was caused by medical management and that results in measurable disability. (QuIC) Adverse eventAn injury that was caused by medical management (rather than underlying disease) and that prolonged the hospitalization produced a disability at the time of discharge, or both. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. New England Journal of Medicine 1991; 324:370-376.Unpreventable adverse eventAn adverse event resulting from a complication that cannot be prevented given the current state of knowledge. (QuIC)

Near missAn error of commission or omission that could have harmed the patient, but serious harm did not occur as a result of chance (e.g., the patient received a contraindicated drug but did not experience an adverse drug reaction), prevention (e.g., a potentially lethal overdose was prescribed, but a nurse identified the error before administering the medication), or mitigation (e.g., a lethal drug overdose was administered but discovered early and countered with an antidote). (IOM)

Near missAn event or situation that could have resulted in an accident, injury or illness, but did not, either by chance or through timely intervention. Doing What Counts for Patient Safety: Federal Actions to Reduce Medical Errors and Their Impact. Report of the Quality Interagency Coordination Task Force to the President, Feb 2000. Quality Interagency Coordination Task Force. Washington, D.C.

Incident reporting A process used to document occurrences that are not consistent with routine hospital operation or patient care. Cullen DJ, Bates DW, Small SD, Cooper JB, Nemeskal AR, Leape LL. The incident reporting system does not detect adverse drug events: a problem for quality improvement. Jt Comm J Qual Improv. 1995; 21(10):541-548.

Risk managementIn the context of hospital operations, the term risk management usually refers to self-protective activities meant to prevent real or potential threats of financial loss due to accident, injury, or medical malpractice. Kraman SS, Hamm G. Risk management: extreme honesty may be the best policy. Ann Intern Med. 1999; 131(12):963-967.

Medical Error

Pasientidak cidera

Pasiencidera

Near Miss

Adverse Event

-Dpt obat “c.i.”, tdk timbul (chance)-Plan, diket, dibatalkan (prevention)-Dpt obat “c.i.”, diket, beri anti-nya

(mitigation)

-Kesalahan proses -Dpt dicegah-Pelaks Plan action tdk komplit-Pakai Plan action yg salah -Krn berbuat : commission-Krn tidak berbuat : omission

(NM)

(AE)

Proses of Care(Non Error) Adverse Event

Pasiencidera

(KTD=Kejadian Tdk Diharapkan)

Gray,A :Adverse events and the National Health Service, an economic perspective, report to the National Patient Safety Agency , November 2003

Figure 1: Venn diagram representing Institute of Medicine terminology

All episodes of care

All Errors

All Adverse Events

PreventableAdverse Events

NegligentAdverse Events

(NearMiss)

(Adverse EventsNon Error)

(UnpreventableAE)

Type of Errors • Diagnostic

Error or delay in diagnosisFailure to employ indicated testsUse of outmoded tests or therapyFailure to act on results of monitoring or testing

• TreatmentError in the performance of an operation, procedure or testError in administering the treatmentError in the close of method of using a drugAvoidable delay in treatment or in responding to an abnormal

testInappropriate (not indicated) care

• PreventiveFailure to provide prophylactic treatmentInadequate monitoring or follow up of treatment

• OtherFailure of communicationEquipment failureOther system failureLeape, Lucian; Lawthers, Ann G.; Brennan, Troyen A., et al. Preventing Medical Injury. Qual Rev Bull. 19(5):144–149, 1993.

“First, do no harm” : Hippocrates (460-335 BC). Pelayanan Kesehatan pada dasarnya adalah untuk “menyelamatkan” pasien

Sejak awal 1900 institusi RS selalu meningkatkan MUTU pada ke-3 elemen tsb diatas : Standar Pelayanan, Penerapan QA, TQM, CQI, Perizinan, Credentialing, Akreditasi, ISO, Baldridge Award, Performance measurement, Benchmarking, Hospital/Clinical Governance, Clinical Indicator, EBM/P, Etik Profesi / RS, Risk Management. . .

Namun : . . . . .

Rumah Sakit :Rumah Sakit :

Process of careProcess of care OutcomeOutcomeStructureStructureQuality QualityQuality

Adverse Event : 3.2 – 16.6 % Adverse Event : 3.2 – 16.6 % !!! !!! (WHO, 2004)(WHO, 2004)

Process of careProcess of care OutcomeOutcomeStructureStructure

Near Miss : Near Miss : Everyday, tens if not hundred Everyday, tens if not hundred thousands of error occur in the US health care system thousands of error occur in the US health care system ….these errors not in serious harm but in Near Miss….these errors not in serious harm but in Near Miss(Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety: (Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety: achieving a new standard for care. Washington, D.C.: National Academy Press, 2004.)achieving a new standard for care. Washington, D.C.: National Academy Press, 2004.)

Quality Quality Quality

“Sektor Yan Kesehatan selama ini tidak rutin mendata informasi tentang error”(Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety: achieving a new standard for care.Washington, D.C.: National Academy Press, 2004.)

RS:RS:

How good is the quality of care ?E.A. McGlynn, 1998 (President’s Advisory Commission on Consumer Protection and Quality in Health Care Industry)

Overuse :

*CABG 14% procedure inappropriate : Inggris 21 %, Canada 9%. * URTI : 30-70% inappropriate prescriptions of antibiotics for viral infection. *NSAIDS : 42% unnecessary prescription Under use :

*76 % anak : immunisasi lengkap. * Pasien DM hanya 16% diperiksa HbA1C. * Pasien dengan CAD perlu intervensi : hanya dilaksanakan 42 % (Black) & 61% (White) yang CABG / PTCAVariasi pelaksanaan YanKes :*Daerah North east : West lebih tinggi : prostatectomy 13%,cholecystectomy 48%, cardiac catheterization 30%, CABG 30%, CT Scan 159%. *South : West : lebih tinggi Hysterectomy 50%. *South : North east : lebih tinggi Appendictomy 32%, S.C. 37%*Midwest : West : lebih tinggi Mastectomy 86%Error :*Medication error 4 per 1000 : terbanyak pd antibiotik, obat cardio-vaskuler, obat gastrointestinal & narkotik. *14% kematian pada stroke, pneumonia dan serangan jantung apat dicegah (12 RS)

Masih ada 3 isu lain disamping error :

(Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: buildinga safer health system. Washington, D.C.: National Academy Press, 2000.)

IOM (Institute of Medicine) : TO ERR IS HUMAN

IOM, 1998 : Committee on quality of Health Care in America membuat laporan :

TO ERR IS HUMAN,TO ERR IS HUMAN, Building a Safer Health System (2000)Building a Safer Health System (2000)

1) Adverse Event bukan baru, namun laporan berhasil mengangkat fokus perhatian : - AE di RS di Colorado & Utah : 2,9 % pasien RS, yang meninggal 6,6 % - Di New York : 3,7 %, yang meninggal 13,6 % - Pasien admisi di RS pada th tsb (1997) 33,6 juta - Extrapolasi : Pasien mati karena Medical Error : 44.000 – 98.000.

(Kohn LT, Corrigan JM, Donaldson MS, eds. To err is human: building a safer health system. Washington, D.C.: National Academy Press, 2000.)

RS AE(>50% krn

ME)

Mati USRS:Adm

/year

USRS:Mati

sb AE/MEExtrapolasi

Mati sb lain

Di Colorado – Utah(1992)

2.9 % 6.6 %

33.6 juta

44,00044,000

--

98,00098,000

!!!!!!

- KLL :

43,458

-Cancer :

42,297

-AIDS :

16,516Di New York(1984)

3.7 % 13.6 %

Laporan IOM: TO ERR IS HUMAN, building a safer health system. Laporan IOM: TO ERR IS HUMAN, building a safer health system.

“Laporan To Err is Human fokus pd ME di RS krn data tersedia. Tetapi di sarana yan kes lain (ambulatory setting & nursing homes) jumlah kunjungan sangat besar ME juga serius, shg ME di RS tampak sangat kerdil. (Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety:achieving a new standard for care. Washington, D.C.: National Academy Press, 2004.)

2) Laporan IOM menyimpulkan 4 hal pokok :A. Masalah accidental injury adalah serius

B. Penyebabnya bukan kecerobohan individu, tetapi kesalahan sistem

C. Perlu redesign sistem pelayanan D. Patient Safety harus menjadi prioritas

nasional3) IOM mengajak (challenge) semua pihak melibatkan diri (Leape L et al, Editorials, New England J. of Medicine 2002, 347 : 1272-1273)

4) Segera Congress mengadakan dengar pendapat. Pres.Clinton membentuk : Quality Interagency Coordination Task Force (QuIC) menganalisa laporan IOM tsb

“The message of the report has resonated ever since, from the halls of Congress to the hallways of health care facilities across the nation.” : Mary K. Wakefield, AHRQ Publication No. 05-0021-4 (Vol. 4), February 2005

(WHO : World Alliance for Patient Safety, Forward Programme, 2004)

KEKERAPAN TUNTUTAN• DI INGGRIS

– TIAP HARI TERJADI KELALAIAN MEDIS• DI AUSTRALIA

– KLAIM DITUJUKAN PADA 11,8 / 1000 PESERTA ASURANSI PROFESI

• DI SINGAPURA– KLAIM DITUJUKAN PADA 10,7 / 1000 PESERTA

ASURANSI PROFESI• DI JAKARTA

– PIDANA: 48 KASUS DI POLDA METRO– PERDATA: 160 KASUS DIAJUKAN LBH KESEHATAN

(Budi Sampurna, Seminar Perumahsakitan, Surabaya, 24 Maret 2005)

Di INDONESIA

*KaDinKes DKI Jkt (8Juli2005): setiap minggu ada 2 – 3 pengaduan pasien

KEKERAPAN ERRORS DI RUMKIT

• DI A.S.:– KESALAHAN PEMBERIAN OBAT DI 2 RUMKIT DI

AS: 56% DAN 34% (BATES, 1995)– KESALAHAN BEDAH : 1:50 PASIEN RAWAT

(GAWANDE, 1999)

• DI INDONESIA:Iwan Dwiprahasto MMedSc, PhD di Jogja:– MEDICATION ERROR DI I.C.U. MENCAPAI 96%

(TAK SESUAI INDIKASI, TAK SESUAI DOSIS, POLIFARMAKA TAK LOGIS, DLL)

– MEDICATION ERROR DI PUSKESMAS: 80-AN %

(Budi Sampurna, Seminar Perumahsakitan, Surabaya, 24 Maret 2005)

AmerikaAmerika1. IOM (Institute of Medicine) : - To err is Human, Building a Safer Health System (2000) - Patient Safety, Achieving a new standard for care (2004) rekomendasikan 3 hal pokok :a. Infrastruktur Sistem Informasi Kesehatan Nasional diperlukan untuk

membuat Standar Keselamatan Pasienb. Semua organisasi kesehatan perlu menetapkan Program

Keselamatan Pasien yang komprehensif dijalankan oleh Staf yang terlatih

c. Perlu standardisasi Pelaporan & Terminologi Keselamatan Pasien

2. AHRQ : Agency for Healthcare Research and Quality (www.ahrq.gov) - 2001 : Center for Quality Improvement and Patient Safety (CQuIPS) - 2003 : “Guide to Patient Safety Indicators” 3. Pres. Clinton : Quality Interagency Coordination Task Force menetapkan kebijakan nasional :

A. Mengangkat suatu Fokus Nasional utk membentuk Kepemimpinan, Riset, Instrumen, Pedoman meningkatkan pengetahuan tentang Keselamtan Pasien

B. Melakukan identifikasi dan belajar dari “medical errors” melalui Sistem Laporan yg wajib maupun sukarela

C. Meningkatkan / memperbaiki standar Keselamtan PasienD. Implementasikan kegiatan keselamatan pasien di ujung tombak

pelayanan

4. JCAHO (Joint Comm. On Accreditation for Healthcare organization) - Setiap tahun menetapkan “National Patient Safety Goals”(sejak 2002) - Juli 2003 : Pedoman “The Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery” - Maret 2005 mendirikan International Center for Patient Safety

5. NPSF : National Patient Safety Foundation. (AMA) - Perbaiki Keseamatan Pasien - Identifikasi & susun “ a core body of knowledge” - Tingkatkan kesadaran publik ttg keselamtan pasien

Australia Australia 1. Australian Council for Safety and Quality in Health Care : - Jan 2000 dibentuk oleh MOH Australia dgn dukungan Australian

Health Ministers. (www.safetyandquality.org) - Fungsi : pimpin kegiatan nasional memperbaiki keselamatan dan

mutu yan kesehatan, utamanya menekan “error” - Tujuan : 1) Kembangkan Standar & Pedoman, 2) Tingkatkan data & analisis AE 3) Berdayakan konsumen utk memperbaiki keselamatan pasien4) Redisain sistem kesehatan, 5) Tingkatkan kesadaran masyarakat ttg

keselamatan pasien

2. APSF : Australian Patient Safety Foundation Inc (July 1989) - Asalnya dari Program Incident Monitoring pada Anestesi

3. Australia’s First Patient Safety Research Centre (Dec 2004) 4. Program AIMS : - Australian Incident Monitoring System

InggrisInggris1. NPSA = National Patient Safety Agency, 2001 Juli : dibentuk

pemerintah / NHS - Koordinasi kegiatan laporan, belajar dari kesalahan dan masalah

keselamatan pasien - Pastikan kesalahan dilaporkan pd kesempatan pertama - Dorong staf kesehatan melapor insiden tanpa takut ditegur - Kumpulkan laporan dari seluruh daerah & prakarsai langkah

pencegahan, shg secara nasional kasus2 dpt dipelajari, dan keselamatan pasien dpt diperbaiki improved.

2. National Reporting and Learning System (NRLS) - Laporan secara elektronik - Laporan bersifat anonim - Menerbitkan : “ : Seven steps to patient safety, An overview guide

for NHS staff “.

CanadaCanada 1. NSCPS : National Steering Committee on Patient Safety : 2. CPSI : Canadian Patient Safety Institute - dibentuk oleh Pemerintah Federal, 2003 - Agenda pokok badan2 ini : Bentuk budaya keselamatan pasie,

tingkatkan mutu yan kesehatan - Rekomendasi

a. Bangun kesadaran dan tentukan prioritas utk memperbaiki keselamatan pasien

b. Kembangkan sistem pelaporan yg lebih baikc. Kembangkan ketrampilan, pengetahuan & implementasi sistem

keselamtan pasiend. Bentuk organisasi & kebijakan yg mendukung kegiatan keselamatan

pasien3. AHSC (Academic Health Services Centre) : riset keselamatan pasien4. ACAHO (Association of Canadian Academic Health care organizations) : strategy keselamatan pasien5. ACEN (Academy of Canadian Executive Nurses) : strategy keselamatan pasien

Denmark Denmark

• Denmark is one place from which practitioners may draw inspiration. • In June 2003 it became the first country to adopt a national law on patient safety. • The law states that hospital operators must receive, register, and analyse reports on adverse events. • A nurse or doctor who becomes aware of such an incident or a near miss must report it. The details are logged in a • national register. • The reports do not include details that can identify people, and medical staff cannot be subjected to disciplinary action for reporting any incidents.

MalaysiaMalaysia Patient Safety Council :

- September 2004, dibentuk oleh MOH - 5 fungsi : 1. Kembangkan sistem database electronik utk pelaporan &

dokumentasi medical errors di RS2. Promosikan sistem pelaporan insiden yg adil dan konfidensial3. Analisa insiden & belajar menghindari/mencegahnya4. Susun strategi memperbaiki keselamatan dan mutu5. Publikasi laporan ttg AE & keselamatan pasien

WHOWHO- Pada World Health Assembly ke 55 Mei 2002 ditetapkan suatu resolusi

yang mendorong (urge) negara untuk memberikan perhatian kepada problem Patient Safety meningkatkan keselamatan dan sistem monitoring

- Okt 2004 WHO dan berbagai lembaga mendirikan “World Alliance for Patient Safety” dgn tujuan mengangkat Patient Safety Goal “First do no harm” dan menurunkan morbiditas, cidera dan kematian yang diderita pasien (www.who.int/patientsafety)

WHOWorld Alliance for Patient Safety

Programme : six areas of action. (2005)1. Global Patient Safety Challenge,focusing over an initial two-year cycle on the challenge of health-care associated infection;2005-2006: "Clean Care is Safer Care“2. Patients for Patient Safety Involving patient organisations and individuals in Alliance work;3. Taxonomy for Patient Safety Ensuring consistency in the concepts, principles, norms and terminology used in patient safety work;4. Research for Patient Safetypromoting existing interventions in patient safety and coordinating international efforts to develop solutions;5. Solutions for Patient Safetypromoting existing interventions in patient safety and coordinating international efforts to develop solutions; and6. Reporting and Learning Generating best practice guidelines for existing and new reporting systems.

(www.who.int/patientsafety)

WHOWorld Alliance for Patient Safety

Programme : six areas of action. (2005)

SPEAK UP (Action 2) :Speak up if you have questions or concerns: it's your right to

knowPay attention to the care you are receivingEducate yourself about your diagnosis, test and treatmentAsk a trusted family member or friend to be your advocateKnow what medications you take and why you take themUse a health-care provider that rigorously evaluates itself

against safety standardsParticipate in all decisions about your care.

NHS-NPSA : Seven steps to patient safety, An

overview guide for NHS staff. Second print April 2004 1 Build a safety culture : Create a culture that is open and fair2 Lead and support your staff : Establish a clear and strong focus on patient safety throughout your organisation3 Integrate your risk management activity : Develop systems and processes to manage your risks and identify and assess things that could go wrong4 Promote reporting : Ensure your staff can easily report incidents locally and nationally5 Involve and communicate with patients and the public : Develop ways to communicate openly with and listen to patients6 Learn and share safety lessons : Encourage staff to use root cause analysis to learn how and why incidents happen7 Implement solutions to prevent harm : Embed lessons through changes to practice, processes or systems

(www.npsa.nhs.uk/sevensteps)

A major element of programmes to improve patient safety is having the capacity and capability to capture comprehensive information on adverse events, errors and near-misses so that it can be used as a source of learning and as the basis for preventive action in the future. (WHO : World Alliance for Patient Safety, Forward Programme, 2004 )

(Seven steps to patient safety, An overview guide for NHS staffApril 2004)

NHS-NPSA : Seven steps to patient safety,

An overview guide for NHS staff. Step 1 Second print April 2004 Build a safety cultureAction points

For your organisation:• ensure your policies state what staff should do following an incident,how it should be investigated, and what support should be given topatients, families and staff;• ensure your policies describe individual roles and accountability forwhen things go wrong;• assess your organisation’s reporting and learning culture using a safetyassessment survey (see ‘Resources from the NPSA’ on page 10).

For your team:• ensure your colleagues feel able to talk about their concerns and reportwhen things go wrong;• demonstrate to your team the measures your organisation takes toensure reports are dealt with fairly and that the appropriate learningand action takes place.

Step 2Lead and support your staffAction points

For your organisation:• ensure there is an executive board member with responsibility forpatient safety;• identify patient safety champions in each directorate, division ordepartment;• put patient safety high on the agenda of board or management teammeetings;• build patient safety into the training programmes for all your staff andensure this training is accessible and measure its effectiveness.

For your team:• nominate your own champion or lead for patient safety;• explain the relevance and importance of patient safety to your team,and the benefits it brings;• promote an ethos where all individuals within your team are respectedand feel able to challenge when they think something may be goingwrong.

Step 3Integrate your risk management activityAction points

For your organisation:• review your structures and processes for managing clinical and nonclinicalrisk, and ensure these are integrated with patient and staffsafety, complaints and clinical negligence, and financial andenvironmental risk;• develop performance indicators for your risk management systemwhich can be monitored by your board;• use the information generated by your incident reporting system andorganisation-wide risk assessments to proactively improve patient care.

For your team:• set up local forums to discuss risk management and patient safetyissues and provide feedback to the relevant management groups;• assess the risk to individual patients in advance of treatment;• have a regular process for assessing your risks, for defining theacceptability of each risk and its likelihood, and take appropriate actionsto minimise them;• ensure these risk assessments are fed into the organisation-wide riskassessment process and risk register.

Step 4Promote reportingAction points

For your organisation:• complete a local implementation plan (see below) which describes howand when your organisation will begin reporting nationally to the NPSA.

For your team:• encourage your colleagues to actively report patient safety incidentsthat happen and those that have been prevented from happening butthat carry important lessons.

Step 5Involve and communicate with patients and the publicAction points

For your organisation:• develop a local policy covering open communication about incidentswith patients and their families;• ensure patients and their families are informed when things have gonewrong and they have been harmed as a result;• provide your staff with the support, training and encouragement theyneed to be open with patients and their families.

For your team:• ensure your team respects and supports the active involvement ofpatients and their families when something has gone wrong;• prioritise the need to tell patients and their families when incidentsoccur, and to provide them with clear, accurate and timely information;• make sure patients and their families receive an immediate apologywhere it is due, and are dealt with in a respectful and sympathetic way.

Step 6Learn and share safety lessonsAction points

For your organisation:• ensure relevant staff are trained to undertake appropriate incidentinvestigations that will identify the underlying causes;• develop a local policy which describes the criteria for when yourorganisation should undertake a Root Cause Analysis (RCA) orSignificant Event Audit (SEA). These criteria should include all incidentsthat have lead to permanent harm or death.

For your team:• share lessons from the analysis of patient safety incidents within yourteam;• identify which other departments might be affected in future, and shareyour learning more widely.

Step 7Implement solutions to prevent harmAction points

For your organisation:• use the information generated from incident reporting systems, riskassessments, and incident investigation, audit and analysis to identifylocal solutions. This could include re-designing systems and processes,and adapting staff training or clinical practice;• assess the risks for any changes you plan to make;• measure the impact of your changes;• draw on solutions developed externally. These could be solutionsdeveloped at a national level by the NPSA or best practice identifiedelsewhere in the NHS;• provide staff with feedback on any actions taken as a result of reportedincidents.

For your team:• involve your team in developing ways to make patient care betterand safer;• review changes made with your team to ensure they are sustained;• ensure your team receives feedback on any follow-up to reportedincidents.

AHRQ : 20 Tips To Help Prevent Medical Errors(untuk Pasien / Masyarakat)

1.The single most important way you can help to prevent errors is to be an active member of your health care team. 2. Make sure that all of your doctors know about everything you are taking. This includes prescription and over-the-counter medicines, and dietary supplements such as vitamins and herbs.3. Make sure your doctor knows about any allergies and adverse reactions you have had to medicines.4. When your doctor writes you a prescription, make sure you can read it.5. Ask for information about your medicines in terms you can understand– both when your medicines are prescribedand when you receive them6. When you pick up your medicine from the pharmacy, ask: Is this the medicine that my doctor prescribed?

Patient involvement : …..in general, patients (and their family & friends) are Patient involvement : …..in general, patients (and their family & friends) are a vastly underutilized resource for identifying things that go wrong in health a vastly underutilized resource for identifying things that go wrong in health care. care. (Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety: (Aspden P, Corrigan JM, Wolcott J, Erickson SM, eds. Patient Safety: achieving a new standard for care. Washington, D.C.: National Academy achieving a new standard for care. Washington, D.C.: National Academy

Press, 2004.)Press, 2004.)

7. If you have any questions about the directions on your medicine labels, ask8. Ask your pharmacist for the best device to measure your liquid medicine. Also, ask questions if you’re not sure how to use it.9. Ask for written information about the side effects your medicine could cause. 10. If you have a choice, choose a hospital at which many patients have the procedure or surgery you need.11. If you are in a hospital, consider asking all health care workers who have direct contact with you whether theyhave washed their hands.12. When you are being discharged from the hospital, ask your doctor to explain the treatment plan you will use at home.

13. If you are having surgery, make sure that you, your doctor, and your surgeon all agree and are clear on exactlywhat will be done14. Speak up if you have questions or concerns.15. Make sure that someone, such as your personal doctor, is in charge of your care.16. Make sure that all health professionals involved in your care have important health information about you.17. Ask a family member or friend to be there with you and to be your advocate (someone who can help get things done and speak up for you if you can’t).18. Know that “more” is not always better.19. If you have a test, don’t assume that no news is good news.20. Learn about your condition and treatments by asking your doctor and nurse and by using other reliable sources.

(www.ahrq.gov/errors.htm.)

AHRQ : 30 Safe Practices for Better Health Care(untuk Staff)

1. Create a health care culture of safety.2. Elective surgical procedures-patients should be clearly

informed- treatment facilities superior outcomes -should be referred to such facilities in accordance with the patient’s stated preference.

3. Specify an explicit protocol to be used to ensure an adequate level of nursing

4. All patients in general intensive care units should be managed by physicians having specific training and certification in critical care medicine (“critical care certified”).

5. Pharmacists should actively participate in the medication-use process6. Verbal orders should be recorded whenever possible and immediately read back to the prescriber;7. Use only standardized abbreviations and dose designations.

8. Patient care summaries or other similar records should not be prepared from memory.9. Care information, especially changes in orders and new diagnostic

information, is transmitted in a timely and clearly understandable form to all of the patient’s current health care

providers who need that information to provide care10. Ask each patient or legal surrogate to recount what he or

she has been told during the informed consent discussion.11. Ensure that written documentation of the patient’s preference for life-sustaining treatments is prominently

displayed in his or her chart.12. Implement a computerized prescriber-order entry system.13. Implement a standardized protocol to prevent the mislabeling of

radiographs.

14. Implement standardized protocols to prevent the occurrence of wrong-site or wrong-patient procedures.

25. Decontaminate hands with either a hygienic hand rub or by washing with a disinfectant soap prior to, and after, direct contact with the patient or objects immediately around the patient.

26. Vaccinate health care workers against influenza to protect both them and patients.

27. Keep workspaces where medications are prepared clean, orderly, well lit, and free of clutter, distraction, and noise.28. Standardize the methods for labeling, packaging, and

storing medications.29. Identify all “high alert” drugs (for example, intravenous

adrenergic agonists and antagonists, chemotherapy agents, anticoagulants and anti-thrombotics, concentrated parenteral

electrolytes, general anesthetics, neuromuscular blockers, insulin and oral hypoglycemics, narcotics, and opiates).

30. Dispense medications in unit-dose or, when appropriate, unit-of-use form, whenever possible.

(www.ahrq.gov/qual/nqfpract.htm.)

How to Prevent Medical MistakesMedical Mistakes Can Happen

A Patient Safety Message brought to you by

• In the Hospital: Because there are hundreds of medications, tests and procedures, and many patients and clinical staff members in a hospital, it is quite easy for a mistake to be made. Such mistakes can include giving someone the wrong medication, performing the wrong tests (such as lab tests or X-rays), performing the wrong procedures, or neglecting to do any of the above when they have been ordered by a doctor.

(Pasien/Masyarakat)

Patient identificationWhether your care giver is taking blood, giving you medication, or performing a test or procedure, you want to make sure that it is meant for you. It is OK to ask your caregiver for whom the test, procedure or medication is intended. “Read Back”Each time a new staff person comes to give you medicationor treatment, greet them and tell them your name. Ask them to tell you their name and explain what the procedure is, whoordered it, and what to expect from it. Ask them to “read back” the order to you. If the information is different than what you expect, alert the staff member immediately, and request anexplanation.Post your name on the wall above your bed.

TABLE 2. CHARACTERISTICS OF SUCCESSFUL REPORTING SYSTEMS.*

Characteristic ExplanationNonpunitive Reporters are free of fear of retaliation

or punishment from others as a result of reporting.

Confidential The identities of the patient, reporter, and institution are never revealed to a third party.

Independent The program is independent of any authority with power to punish the reporter or organization.

Expert analysis Reports are evaluated by experts who understand the clinical circumstancesand who are trained to recognize underlying systems causes.

Pelaporan

Reporting of Adverse Events: Leape, L.L., N Engl J Med, Vol. 347, 1633-1638, 2002

Timely Reports are analyzed promptly, and recommendations are rapidly disseminated to those who need to know, especially when serious hazards are identified.

Systems-oriented Recommendations focus on changes in systems, processes, or products, rather than on individual performance.

Responsive The agency that receives reports is capable of disseminating recommendations, and participating organizations agree to implementing recommendations when possible.

*Adapted from Cohen,22 Connell,30 Cohen,36 and Gaynes et al.37

Reporting of Adverse Events: Leape, L.L., N Engl J Med, Vol. 347, 1633-1638, 2002

TABLE 3. LIST OF SERIOUS REPORTABLE EVENTS.*Surgical events•Surgery performed on the wrong body part•Surgery performed on the wrong patient•Wrong surgical procedure performed•Retention of foreign object in a patient after surgery or another procedure•Death of patient with an ASA class I risk during or immediately after surgery†Events involving products or devices•Death or serious disability associated with the use of contaminated drugs, devices, or biologics provided by the health care facility•Death or serious disability associated with the use or function of a device that is other than the intended use or function•Death or serious disability associated with intravascular air embolism that occurs while the patient is receiving care in a health care facility (Reporting of Adverse Events: Leape, L.L., N Engl J Med,

Vol. 347, 1633-1638, 2002)

Events involving patient protection•Infant discharged to the wrong person•Death or serious disability associated with a patient’s disappearance for more than four hours•Suicide, or attempted suicide resulting in serious disability, while patient is receiving care in a health care facilityEvents involving care•Death or serious disability associated with a medication error (e.g., an error involving the wrong drug, wrong dose, wrong patient, wrong time, wrong rate, wrong preparation, or wrong route of administration)•Death or serious disability associated with a hemolytic reaction due to the administration of ABO-incompatible blood or blood product•Death or serious disability associated with labor or delivery in a low-risk woman receiving care in a health care facility•Death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is receiving care in a health care facility

•Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in a neonateStage III or IV pressure ulcers acquired after admission to a health care facility•Death or serious disability due to spinal manipulative therapyEnvironmental events•Death or serious disability associated with an electric shock while patient is receiving care in a health care facility•Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances Death or serious disability associated with a burn incurred while patient is receiving care in a health care facility•Death associated with a fall while patient is receiving care in a health care facility Death or serious disability associated with the use of restraints or bedrails while patient is receiving care in a health care facility

Criminal events•Any instance of care ordered or provided by someone impersonating a physician, nurse, pharmacist, or other health care provider•Abduction of a patient of any age•Sexual assault on a patient within or on the grounds of a health care facility•Death or serious injury of a patient or staff member resulting from a physical assault (i.e., battery) within or on the grounds of a health care facility*Modified from the National Quality Forum.25†ASA denotes American Society of Anesthesiology.

Reporting of Adverse Events: Leape, L.L., N Engl J Med, Vol. 347, 1633-1638, 2002

Mengapa Patient Safety

Process of careProcess of care OutcomeOutcomeStructureStructure : AE

“Blaming”-Pengaduan, Tuntutan-Tuduhan “Malpraktek”(Pid/Perd)-Proses Hukum:Polisi,Pengadilan-Blow-up Mass Media, 90% Publikasi-opini negatif-“Pertahanan RS” :

-Pengacara-RS/Dr : Asuransi-Tuntutan balik

- Dsb

Patient Safety-Culture-Reporting-Learning/Analysis/Research

-K&R-based Standard-Guideline-Implementasi,Monitor-Patient Involvement

Costly

Kecurigaan meningkat

Kepercayaan meningkat

Cost: Invsment

Quality Quality Quality

RS:RS:

“ “ BLAMING ”BLAMING ”

“ “ PATIENTPATIENTSAFETY ”SAFETY ”

2005 2008 2010

Manfaat RS terapkan Keselamatan Pasien Kecenderungan “Green Product” -produk yang aman- di bidang industri lain, al.menjadi persyaratan dlm berbagai proses transaksi, sehingga menjadi makin laku/laris, makin dicari masyarakat RS yang menerapkan KP akan lebih ”dicari” oleh ”3rd Party Payer” : Perusahaan-perusahaan dan Asuransi-asuransi akan mengutamakan memakai RS-RS tsb sebagai provider kesehatan karyawan / klien mereka, & kemudian akan diikuti oleh masyarakat yang akan lebih mencari RS yang aman. Kegiatan RS di kawasan Blaming akan menurun krn fokus di kawasan Patient Safety,

Kesimpulan Kesimpulan

1) Di berbagai negara yang notabene adalah negara maju, termasuk mutu pelayanan kesehatan dan teknologi kesehatannya, tenyata Medical Error yang berakibat “Adverse Event” (AE) tidak kecil jumlahnya. Apalagi “Near Miss” ada 10-100 ribuan tiap hari di US (Disamping : Overuse, Underuse, Variasi Pelayanan)

2) Di Indonesia data AE ini masih minim, tetapi diasumsikan tidak kalah besarnya

3) AE meningkatkan biaya, proses2 “Blaming” merugikan semua pihak, kecurigaan meningkat, “semua pihak rugi” :“lose-lose outcome”

4) Patient Safety / Keselamatan Pasien adalah solusi yang menguntungkan: “win-win situation”, kepercayaan meningkat. Di banyak negara sejak th2000an Patient Safety sudah diangkat menjadi fokus nasional, partisipasi luas berbagai organisasi

5) Elemen pokok Sistem Keselamatan Pasien, yang bertujuan menekan kejadian AE, terdiri dari :

I. ReportingII. Analyzing /Learning, Research, TaxonomyIII. Solution development IV. Knowledge & Research based Standards-

Practices-Guidelines for Patient SafetyV. Patient involvement-empowerment

KOMITE KESELAMATAN PASIEN KOMITE KESELAMATAN PASIEN RUMAH SAKITRUMAH SAKIT

K K P – R S K K P – R S @PERSI, 2005

Latar belakang Latar belakang

- Data AE di negara maju tidak kecil, WHO : data AE di rumah sakit : 3 – 16 % yaitu di Amerika, Australia, Inggris, Denmark dan New Zealand - Di Indonesia data AE ini masih minim- Sejak th 2000an berbagai Negara mengembangkan dan menerapkan konsep serta strategi Patient Safety dengan tujuan utama menekan AE- WHO pada th 2004 membentuk : World Alliance for Patient Safety- Menilik akan permasalahan yang terkait dengan keselamatan pasien, serta maraknya tuduhan ”Malpraktek” di RS-RS Indonesia dan perkembangan gerakan-gerakan keselamatan pasien di dunia internasional tsb diatas, maka PERSI mengambil inisiatif untuk membentuk suatu komite yang menggerakkan dan berupaya mengangkat fokus Keselamatan Pasien di Indonesia.

OrganisasiOrganisasi

Komite Keselamatan Pasien Rumah Sakit (KKP-RS) diangkat dan bertanggung jawab kepada Pengurus Pusat PERSI.

Keanggotaan KKP-RS terdiri dari individu-individu yang berasal dari lingkungan DepKes, Rumah Sakit Pemerintah dan Swasta, serta dari berbagai organisasi a.l. IDI, PDGI, PPNI, IBI, ISFI, KARS, Fakultas Kedokteran, Konsil Kedokteran Indonesia, Yayasan Pemberdayaan Konsumen Kesehatan Indonesia,

Mantan anggota DPR dsb

VisiVisi Meningkatnya Keselamatan Pasien dan Mutu Pelayanan Rumah Sakit

Misi Misi * Mengangkat secara nasional Fokus Keselamatan

Pasien * Mendorong terbentuknya Kepemimpinan dan Budaya

Rumah Sakit yang mencakup Keselamatan Pasien dan Peningkatan Mutu Pelayanan

* Mengembangkan Standar – Pedoman Keselamatan Pasien berbasis riset dan pengetahuan

* Bekerja sama dengan berbagai Lembaga yang bertujuan meningkatkan Keselamatan Pasien dan Mutu Pelayanan Rumah Sakit

Aktivitas KP-RSAktivitas KP-RSAEAE

WaktuWaktu

*Sadar KP*Sadar KP -Awareness--Awareness-

*Komitmen KP di RS*Komitmen KP di RS

*Kepemimpinan KP di RS*Kepemimpinan KP di RS --Leadership-Leadership-

*Budaya KP di RS*Budaya KP di RS

*Sistem KP di RS*Sistem KP di RS

00

Strategi Pengembangan Keselamatan Pasien RSStrategi Pengembangan Keselamatan Pasien RS

Kepengurusan KKP-RSKepengurusan KKP-RS

• Pelindung : DirJen Yan Medik • Penasehat• Pengurus

- Ketua, Wakil Ketua- Sekretaris- Bidang Kajian Keselamatan Pasien - Bidang Program Keselamatan Pasien- Bidang Pendidikan & Latihan- Anggota

PELINDUNG Direktur Jenderal Pelayanan Medik Departemen Kesehatan RI

PENASEHATKetua Umum PERSI PUSATKetua MAKERSI PUSATKetua KARS (Komisi Akreditasi RS)

PENGURUSKetua merangkap Anggota : Dr. Nico A. Lumenta, K. Nefro, MMWakil Ketua I merangkap Anggota : Dr. Mgs. Johan T. Saleh, MScWakil Ketua II merangkap Anggota : Dr. Boedihartono, MHASekretaris I merangkap Anggota : DR. Rokiah Kusumapradja, SKM, MHA Sekretaris II merangkap Anggota : Dr. Luwiharsih, MScBidang Kajian Keselamatan PasienKoordinator merangkap Anggota : Dr. Alex Papilaya, DTPHWakil Koordinator merangkap Anggota : DR. Dr. Herkutanto, SpF, SH, FaclmWakil Koordinator merangkap Anggota : Dr. Wasista Budiwaluyo, MHABidang Program Keselamatan PasienKoordinator merangkap Anggota : Dr. Muki Reksoprodjo, SpOGWakil Koordinator merangkap Anggota : Dr. Grace Frelita, MMWakil Koordinator merangkap Anggota : Dr. HM. Natsir Nugroho, SpOG, M.KesBidang Pendidikan dan PelatihanKoordinator merangkap Anggota : Dr. Robby Tandiari SpRadWakil Koordinator merangkap Anggota : Dr. Sutoto, M.Kes

ANGGOTADr. Adib A. Yahya, MARSDr. Samsi Jacobalis, SpBDr. Farid Husain, SpB(K)Dr. G. Pandu Setiawan, SpKJDr. Iwan Dwiprahasto, M.Med.Sc, PhD Dr. Hermansyur Kartowisastro, SpBDDr. H.A. Sanoesi Tambunan, SpPD,KR Dr. Koesno Martoatmodjo, SpA, MMDr. Marius Widjajarta, SEDr. Hanna Permana Subanegara, MARSDr. Buddy HW Utoyo, MARSDr. Robert Imam SutedjaH.M. Ali Taher Parasong, SH, MhumDr. Tjandra Y. Aditama, SpP(K), MARSDr. Guntur Bambang Hamurwono, SpM Dr. Untung S. Suseno, M.KesDr. Budi Sampurna, SpF, SHJohanna Kawonal, SMIP, CV.RNLaurensia Lawintono, MScDrg.H.Edi Sumarwanto, MM

Cakupan Tugas BidangCakupan Tugas Bidang

Bidang Kajian Keselamatan Pasien- Pengkajian Laporan KP-RS- Riset KP-RS- Pengembangan Solusi KP-RS- Penyusunan Panduan, Pedoman, Standar, Indikator KP-RS- Penyusunan Taxonomi KP

Bidang Program Keselamatan Pasien- Perencanaan & Pelaksanaan Program Komunikasi / Social Marketing- Perencanaan & Pelaksanaan Program Kerjasama dgn Pemerintah/Lembaga/Organisasi/LSM Kesehatan- Pengembangan Sistem Pelaporan KP-RS

Bidang Pendidikan & Latihan- Perencanaan & Pelaksanaan Pelatihan, Lokakarya, Seminar- Penerbitan & Distrbusi Dokumen KKP-RS

PelaporanPelaporanNM/AENM/AE

Pengkajian/RisetPengkajian/RisetBelajarBelajar

PengembanganPengembanganSolusiSolusi

PanduanPanduanPedomanPedomanStandarStandar

PelatihanPelatihanSeminarSeminar

Implementasi &Implementasi &““Measurement”Measurement”

Siklus Kegiatan Pokok KKP-RSSiklus Kegiatan Pokok KKP-RS

YAN RSYAN RSyang lebih yang lebih

amanaman

@PERSI, 2005

TaxonomyTaxonomyIstilahIstilah

PatientPatientInvolvementInvolvement

Program KKP-RSProgram KKP-RS

1. Sosialisasi KKP-RS dan Konsep Keselamatan Pasien : presentasi di berbagai Pertemuan Nasional Organisasi-organisasi Kesehatan, Asosiasi Fakultas Kedokteran & Fakultas Keperawatan, LSM Kesehatan di Indonesia, Asosiasi Perusahaan Asuransi, MNC, dsb(Seminar Nasional PERSI Agustus 2005 : ceramah KP, KKP-RS & beberapa produknya)

2. Pembentukan Sistem Pelaporan AE di rumah sakit : laporan bersifat anonim dan rahasia

3. Pengkajian, Riset, Analisis / belajar, dari kasus-kasus yang ada

4. Pengembangan dan Publikasi : Solusi, Panduan, Pedoman, Standar, Indikator - Keselamatan Pasien

Program KKP-RS (2)Program KKP-RS (2)

5. Implementasi Standar Keselamatan Pasien melalui Pelatihan-pelatihan, Lokakarya, melalui KARS (Komisi Akreditasi Rumah Sakit) dsb

6. Pengembangan Kerjasama dgn Pemerintah /Lembaga /Organisasi /LSM Kesehatan

7. Pengembangan Taksonomi : Konsep, Prinsip, Norma, Istilah dalam bidang Keselamatan Pasien

Potensi Kendala / HambatanPotensi Kendala / Hambatan

* Inisiatif & Prosedur Pelaporan Near Miss/Adverse Event * Pelaporan NM / AE oleh RS-RS ke KKP-RS * Partisipasi Kelompok Dokter khususnya yg di RS * Pencetakan-Penyebaran Publikasi/Brosur Pedoman

Lain-lainLain-lain

* KKP-RS bukan badan Regulator, Investigatif * Dukungan DepKes, DinasKes, RS, kalangan Profesi Kesehatan, LSM Kesehatan

KesimpulanKesimpulan1) Di Indonesia Konsep Patient Safety / Keselamatan Pasien

yang komprehensif belum banyak dikenal. 2) Bagian-bagiannya sudah dilaksanakan a.l.: Pinok, K3 (Keselamatan Kerja, Kebakaran, Kewaspadaan Bencana), , Informed consent, Audit Klinis, Risk Management3) Proses2 di kawasan “Blaming” dgn maraknya tuduhan

malpraktek melelahkan & merugikan semua pihak. 4) Dengan terbentuknya Komite Keselamatan Pasien Rumah

Sakit (KKP-RS) pd th 2005, Indonesia praktis belum tertinggal dalam upaya menolong masyarakat Perumahsakitan dan Konsumennya menekan AE, keluar dari situasi Medical Error yang berbias ke Malpraktek. Disadari kendala akan cukup berat, butuh partisipasi berbagai organisasi & LSM kesehatan

5) Fokus Nasional di bidang Kesehatan yg “besar/menonjol”:* Keluarga Berencana* Keselamatan Pasien (?)

TerimakasihTerimakasih Atas Atas

perhatiannyaperhatiannya

Komite Keselamatan Pasien Rumah SakitP E R S I

Dr. Nico A. Lumenta, K.Nefro, MM