Scribd Logo
Upload

Welcome to Scribd!

  • 37 views

    Dr. Dr. Andry, MM, MH Kes

    Uploaded by

    rohishatulilmiyah
    The document discusses patient safety issues in hospitals including medical errors that cause deaths, unnecessary procedures, and infections. It provides statistics on sentinel events and common types of events reported in the US. It also discusses Joint Commission International accreditation standards that relate to patient centered care, health care organization management, and academic medical centers. The document outlines five key areas for quality and safety: leadership and accountability, competent workforce, safe environment, clinical care, and quality improvement. It provides examples of criteria within each area.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Dr. Dr. Andry, MM, MH Kes

    Uploaded by

    rohishatulilmiyah
    37 views50 pages
    The document discusses patient safety issues in hospitals including medical errors that cause deaths, unnecessary procedures, and infections. It provides statistics on sentinel events and common types of events reported in the US. It also discusses Joint Commission International accreditation standards that relate to patient centered care, health care organization management, and academic medical centers. The document outlines five key areas for quality and safety: leadership and accountability, competent workforce, safe environment, clinical care, and quality improvement. It provides examples of criteria within each area.

    Original Description:

    reaksi

    Original Title

    Lep321-329

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The document discusses patient safety issues in hospitals including medical errors that cause deaths, unnecessary procedures, and infections. It provides statistics on sentinel events and common types of events reported in the US. It also discusses Joint Commission International accreditation standards that relate to patient centered care, health care organization management, and academic medical centers. The document outlines five key areas for quality and safety: leadership and accountability, competent workforce, safe environment, clinical care, and quality improvement. It provides examples of criteria within each area.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    37 views50 pages

    Dr. Dr. Andry, MM, MH Kes

    Uploaded by

    rohishatulilmiyah
    The document discusses patient safety issues in hospitals including medical errors that cause deaths, unnecessary procedures, and infections. It provides statistics on sentinel events and common types of events reported in the US. It also discusses Joint Commission International accreditation standards that relate to patient centered care, health care organization management, and academic medical centers. The document outlines five key areas for quality and safety: leadership and accountability, competent workforce, safe environment, clinical care, and quality improvement. It provides examples of criteria within each area.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 50

    Dr. dr.

    Andry,MM, MH Kes
    Hospital
    Hospital Problems …

    • Patient Safety
    • Medico Legal Cases
    • Defensive Medicine
    Patient Safety
    • 25% kematian di RS kemungkinan dapat dicegah
    • 180.000 pasien meninggal setiap tahun akibat
    cedera iatrogenik
    • KTD akibat pemberian obat menyebabkan 770.000
    cedera dan kematian
    • Pembedahan yang tidak perlu menyebabkan
    kematian 12.000 pasien
    • 20.000 pasien meninggal akibat infeksi yang
    diperoleh di RS karena petugas tidak cuci tangan
    (Hyman, D.A., 2005)
    Sentinel Event Experience in the US
    Of 4064 sentinel events reviewed by the Joint Commission, January
    1995 through December 2006:

    531 events of wrong site 125 perinatal death/injury


    surgery 94 transfusion-related events
    520 inpatient suicides 85 infection-related events
    488 operative/post op 72 deaths following elopement
    complications
    385 events relating to 66 fires
    medication errors 67 anesthesia-related events
    302 deaths related to delay 51 retained foreign objects
    in treatment
    763 “other”
    224 patient falls
    153 deaths of patients in
    restraints
    138 assault/rape/homicide = 4064
    Top 10 types of sentinel events reported to The Joint
    Commission:
    1. Wrong-site surgery
    2. Delay in treatment
    3. Operative and postoperative complications
    4. Unintended retention of foreign body
    5. Patient suicide
    6. Patient fall
    7. Other unanticipated event
    8. Medication errors
    9. Criminal event
    10. Perinatal death/loss of function
    Jika Safety dan Quality Care
    diterapkan di Rumah Sakit.
    Anything that Can Go Wrong, Will Go
    Wrong
    RS. Kabupaten
    Joint Commission International
    Joint Commission International

     JCI has been working with health care organizations,


    ministries of health, and global organizations in over 80
    countries since 1994.
     In June 2011, JCI received 4 year accreditation by the
    ISQua  meet the highest international benchmarks for
    accreditation entities
     WHO dedicated exclusively to patient safety solutions, is a
    joint partnership between the WHO, The Joint
    Commission, and JCI.
    Occ
    Health &
    Safety
    Infection
    I.T
    Control

    Corporat
    e Business
    Analyst
    Account

    Quality
    Customer Ancillary
    Relation
    & Service
    Risk

    Product
    Nursing
    Dept

    Human
    Support
    Resource
    Service
    s
    Finance &
    Acct
    Patient Centered Standards

     International Patient Safety Goals


     Access to Care and Continuity of Care
     Care of Patients
     Assessment of Patients
     Anesthesia and Surgical Care
     Patient and Family Rights
     Patient and Family Education
     Medication Management and Use
    Health Care Organization Management Standards

    Staff Qualifications and Educations


    Governance, Leadership and Direction
    Facility Management and Safety
    Management of Communication and Information
    Quality Improvement and Patient Safety
    Prevention and Control of Infections
    Academic Medical Center Hospital Standards

    • Medical Professional Education (MPE)


    • Human Subject Research Programs (HRP)
    5 area yang berhubungan dg quality and safety:
    1. Proses Kepemimpinan dan Accountability
    2. Tenaga kerja yang kompeten
    3. Lingkungan aman untuk Staf dan Pasien
    4. Perawatan pasien
    5. Meningkatkan Quality and Safety
    Overview of Risk Areas
    Risk Area
    1 2 3 4 5
    Criteria Leadership Process Competent and Capable Safe Environment for Clinical Care and Improvement of
     and Accountability Workforce Staff and Patients Patients Quality and Safety
    Leadership
    1 responsibilities Personnel files and job Regular inspection Correct patient There is an adverse
    and accountabilities descriptions for all staff of buildings identification event reporting system.
    identified
    Leadership for quality
    2 and Review of credentials Control of hazardous Informed consent Adverse events
    safety of physicians materials are analyzed.
    Collaborative
    3 management Review of credentials of Fire safety program Medical and nursing High-risks processes
    nurses assessments for all and high-risk patients
    patients are monitored.
    4 Oversight of contracts Review of credentials of Biomedical equipment Laboratory services are Patient satisfaction
    other health professionals safety available and reliable is monitored.

    5 Integration of quality and Staff orientation to Stable water and Diagnostic imaging Staff satisfaction is
    risk management their jobs electricity sources services are available, monitored.
    safe, and reliable.
    Compliance with laws
    6 and Oversight of students and Coordination of infection Planned and provided There isa complaint
    regulations those in training prevention and control care is written process.
    program
    7 Commitment to patient Training in resuscitative Reduction of health care Anesthesia and Clinical guidelines and
    and family rights techniques associated infections sedation are used pathways are available
    (hand hygiene) appropriately and used
    8 Policies and procedures Staff education on infection Barrier techniques are Surgical services are Staff understand how
    for care of high-risk prevention and control used (cloves, masks, approproate to to improve processes.
    patients and so on) patient needs.
    Oversight of human
    9 subject Communication among Proper disposal of Medication use is Clinical outcomes are
    research those caring for the patient sharps and needles safely managed monitored.
    10 Organ procurement, Staff health and safety Proper disposal of Patients are educated Communicating
    donation, and program infections medical to participate in their quality and safety
    • Penilaian dan perawatan / pelayanan
    • Prosedur analitik (berlaku untuk tes laboratorium)
    • Manajemen informasi
    • Dokter yang dikredensial
    • Pengontrolan infeksi
    • Komunikasi
    • Penggunaan alat
    • Pengetahuan dan aktivitas peningkatan mutu
    • Manajemen pengobatan
    • Struktur organisasi
    • Orientasi dan pelatihan
    • Keselamatan pasien
    • Lingkungan fisik
    • Hak dan etika
    • Staf
    • Baseline Data
    • Quality Improvement
    • Achievement/Validation
    • Identifikasi komponen yang berdampak pada keselamatan
    • Merancang pendekatan untuk mengatasi resiko
    • Menerapkan perubahan
    • Secara berkala meninjau kembali dampak dari perubahan
    • Menetapkan level resiko untuk patient safety
    • Mengembangkan strategi untuk mengurangi resiko
    • Alokasikan SDM untuk meningkatkan kualitas dan safety
    CONSEQUENCE
    LIKELIHOOD Serious Major Moderate Minor Minimum

    Frequent 1 1 2 3 3

    Likely 1 1 2 3 4

    Possible 1 2 2 3 4

    Unlikely 1 2 3 4 4

    Rare 2 3 3 4 4

    PROBABILITY
    CATEGORIES DEFINITION
    Frequent Is expected to occur again either immediately or within a short period of
    time (likely to occur most weeks or months)
    Likely Will probably occur in most circumstances (several times per year)
    Possible Possibly will re-cur – might occur at some time (may happen every 1-2
    years)
    Unlikely Possibly will recur (could occur at some time in 2-5 years)
    Rare Unlikely to recur – may occur in exceptional circumstances (may happen
    every 5-30 years)
    • Safe Culture

    • Safe Care
    • Safe Staff
    • Safe Support System
    • Safe Place
    • Safe Patients
    Blame Free
    Leadership
    Trust

    Communication
    Team Work
    Commitment
    • Sistem Incident Report  belajar dari pengalaman
    • Blame-free Environment  Yang melakukan kesalahan
    tidak harus di hukum

    • Komunikasi (disusun dengan baik, berulang & konsisten)


     Progres Integrasi dicatat
     Read back
     Morning report
     Death case report
     Coordination meeting
     Monthly meeting
     Dashboard Indicator
    • Belajar dari Kesalahan
    • Seseorang yang mengakui
    kesalahan Tidak Perlu
    Dihukum
    • KTD, eror dan near-misses  Tindakan Pencegahan
    • Meningkatkan kualitas secara keseluruhan dari patient care
    • Farmasi :
     Medication prescribing (E Presc)
     Identifikasi (Name, MR/DOB)
     Persiapan
     Dispensing
     Penyimpanan
     Administrasi
     Pengawasan  Pharmacho Therapy Committee
     Dokumentasi
    • Medical Devices, Transfusi Darah
    " Every Patient's Right, Everyone's Responsibility"
    • Harus berperan aktif menghindari error dan memastikan patient
    safety.
    • Human Resources Department:
     Recruitment
     Kredensial
     Privilege
     Program Orientasi
     Appraisal
    • Kerja Berlebihan
    • Penempatan, Job design
    • Handover
    • Staff Temporary
    • Training and Education :
    o Pendidikan Spesifik dan building a culture of safety
    o Internal dan outside training
    o Article/information

    • Mendidik setiap orang untuk meningkatkan safety and


    quality
    oRoot Cause Analysis (RCA)
    oPlan-Do-Study-Act (PDSA)
    Basic Life Support
    • Orang yang Tepat
    • Waktu yang Tepat
    • Informasi yang Benar
     - IT Department
    - Laboratory Information System
    - Computer Radiology
    - Building Automatic System
    - E Prescription
    • Keterlibatan Pasien di dalam patient safety
    • Memberitahukan kepada pasien semua yang terjadi
    • Speak Up Brochures
    • Banners
    • Opini Pasien
    • Suggestion Box
    • Patient Liaison
    • Translator
    • Informatif
    • Komunikatif
    Meliputi Seluruh Bagian Organisasi (rumah sakit)

    Manajemen Rumah Sakit

    Sistem Pelayanan & Perawatan

    Fokus Pada Pengalaman Pasien Selama Dirawat


    (Patient Tracers)

    Dilakukan Secara Pro-Aktif & Berkesinambungan


    Metode evaluasi untuk memeriksa kinerja rumah
    sakit secara efektif yang tercermin dalam
    pengalaman pasien saat dirawat di rumah sakit
    Build Culture
    • General Awareness
    • Mengikuti pelatihan
    • Membeli Refrensi dari JCI
    • Mengikuti & Menerapkan JCI Standards
    • Studi banding
    • Konsultasi
    • Regular Meeting
    • Simple dan Singkat
    • Jelas, Konsisten dan Mudah
    dilakukan
    • Berkelanjutan
    • Tanggung Jawab Semua Pihak
    Quality
    Safety
    Culture
    TERIMA KASIH

    You might also like