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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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BUDAYA SAFETYBUDAYA SAFETY
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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BUDAYA SAFETYBUDAYA SAFETY
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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BUDAYA SAFETYBUDAYA SAFETY
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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BUDAYA SAFETYBUDAYA SAFETY
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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MANFAAT BUDAYA SAFETYMANFAAT BUDAYA SAFETY
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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MANFAAT BUDAYA SAFETYMANFAAT BUDAYA SAFETY
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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MANFAAT BUDAYA SAFETYMANFAAT BUDAYA SAFETY
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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MANFAAT BUDAYA SAFETYMANFAAT BUDAYA SAFETY
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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MANFAAT BUDAYA SAFETYMANFAAT BUDAYA SAFETY
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)
Reliability of this dimensionReliability of this dimensionCronbachCronbachss alpha (4 items) = .75alpha (4 items) = .75
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.
Reliability of this dimensionReliability of this dimensionCronbachCronbachss alpha (4 items) = .83alpha (4 items) = .83
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)
Reliability of this dimensionReliability of this dimensionCronbachCronbachss alpha (4 items) = .8alpha (4 items) = .8
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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ACTION RECOMMENDATIONS
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.
ACTION RECOMMENDATIONS
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ACTION RECOMMENDATIONS
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.
ACTION RECOMMENDATIONS
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ACTION RECOMMENDATIONS
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.
ACTION RECOMMENDATIONS
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ACTION RECOMMENDATIONS
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.
ACTION RECOMMENDATIONS
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ACTION RECOMMENDATIONS
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.