Patient safety
Sharon Gondodiputro dr., MARS, MH
Department of Public Health,Faculty of Medicine UNPAD
Topics
1.
2.
3.
4.
5.
Definition patient safety
Definition of error
Human factors in patient safety
Problem solving cycle in patient safety
7 steps of patient safety
Definition
• WHO, A discipline in the health-care sector that :
– applies safety science methods towards the goal of achieving a
trustworthy system of health-care delivery
– an attribute of health-care systems
– it minimizes the incidence and impact of and maximizes recovery
from adverse events
• Permenkes 1691 : suatu sistem dimana rumah sakit membuat
asuhan pasien lebih aman yang meliputi:
– asesmen risiko, identifikasi dan pengelolaan hal yang berhubungan
dengan risiko pasien,
– pelaporan dan analisis insiden,
– kemampuan belajar dari insiden dan
– tindak lanjutnya serta implementasi solusi untuk
meminimalkan timbulnya risiko dan mencegah terjadinya cedera yang
disebabkan oleh kesalahan akibat melaksanakan suatu tindakan atau
tidak mengambil tindakan yang seharusnya diambil.
Definisi Insiden (
Permenkes 1691
)
Kejadian Tidak Diharapkan, (KTD) :
insiden yang mengakibatkan cedera
pada pasien
Kejadian sentinel : KTD yang
mengakibatkan kematian atau cedera
yang serius.
Insiden:
setiap kejadian yang tidak disengaja dan
kondisi yang mengakibatkan atau
berpotensi mengakibatkan cedera yang
dapat dicegah pada pasien
Kejadian Tidak Cedera (KTC ): insiden
yang sudah terpapar ke pasien, tetapi
tidak timbul cedera.
Kondisi Potensial Cedera (KPC): kondisi
yang sangat berpotensi untuk
menimbulkan cedera, tetapi belum
terjadi insiden
Kejadian Nyaris Cedera (KNC) :
terjadinya insiden yang belum sampai
terpapar ke pasien.
Human factors
design principles
Psychomotor
- Hands
Senses
- Vision
- Hearing
I
N
T
E
R
F
A
C
E
Input Devices
- Buttons
Output
- Display
- Sound
US Department of Veteran affairs
Traps in health care?
• look-alike and sound-alike
pharmaceuticals
• equipment design
○ e.g. infusion pumps
Ruang ICU
What is an error?
• the failure of a planned action to achieve its intended
outcome
• a deviation between what was actually done and what
should have been done
Reason
• A definition that may be easier to remember is:
○ “Doing the wrong thing when meaning to do the right
thing.”
Situations associated with an
increased risk of error
• unfamiliarity with the task*
• inexperience*
• shortage of time
• inadequate checking
• poor procedures
• poor human equipment interface
Vincent
* Especially if combined with lack of supervision
Individual factors that predispose to
error
• limited memory capacity
• further reduced by:
○ fatigue
○ stress
○ hunger
○ illness
○ language or cultural factors
○ hazardous attitudes
Don’t forget ….
If you’re
– H ungry
– A ngry
– L ate
or
– T ired …..
H
A
L
T
A performance-shaping factors “checklist”
Jensen, 1987
Sistem Pelayanan Kesehatan
di Rumah Sakit
Comsumption of
resources
How the process
of health services
Who provide health care
Who receive health care
Feedback dan TQM
5.Translating
Evidence into safer
care (pelaksanaan
dan perencanaan
kembali)
1. Measuring harm
(mengukur insiden)
4.Evaluating Impact
(evaluasi impact)
2. Understanding causes
(mengerti/mencari
penyebab)
3.Identify solution
(Identifikasi solusi)
1. Measuring harm
Sasaran Keselamatan Pasien
1.
2.
3.
4.
5.
6.
Ketepatan identifikasi pasien: dua identitas atau
penggunaan gelang pasien
Peningkatan komunikasi yang efektif: persentase
kelengkapan rekam medik,audit klinik/keperawatan
Peningkatan keamanan obat yang perlu diwaspadai:
persentase pemberian obat yang salah
Kepastian tepat-lokasi, tepat-prosedur, tepat-pasien operasi:
persentase penandaan lokasi operasi
Pengurangan risiko infeksi terkait pelayanan kesehatan:
persentase tertusuk jarum, ILO, ISK, pneumonia, cuci tangan
yang benar
Pengurangan risiko pasien jatuh: lantai licin,penggunaan
tempat tidur berpagar, asessment pasien risiko jatuh
2. Understand causes
Reason’s swiss model: Multiple factors
usually involved
Vincent funnel : Multiple factors
usually involved
organizational factors
environmental factors
team factors
technology and tool
task factors
provider
patient
1.
2.
Cause
1.
2.
3.
Organizational/technical
factor
Human factor
Level 1:
communication
Level 2: patient
management
Level 3: Clinical
performance pra,
durante dan post
intervention
Type
Domain
1.
2.
Medical :fisik,psikis
Nonmedical: legal,
economy,social
Impact
1.
2.
3.
4.
Setting/location
Staff
Patient
Target
3. Identify Solution
Causes
Type
Domain
Impact
Preventive/Mitigation
1.
2.
3.
Universal
Selective
Indication
5.Translating
Evidence into safer
care (pelaksanaan
dan perencanaan
kembali)
1. Measuring harm
(mengukur insiden)
4.Evaluating Impact
(evaluasi impact)
2. Understanding causes
(mengerti/mencari
penyebab)
3.Identify solution
(Identifikasi solusi)
• A safety culture is where organisations, practices,
teams and individuals have a constant and active
awareness of the potential for things to go wrong.
Both the individuals and the organisation are able to
acknowledge mistakes, learn from them, and take
action to put things right.
Being open and fair means sharing information openly
and freely with patients and their families, balanced
by fair treatment for staff when an incident happens.
This is vital for both the safety of patients and the
wellbeing of those who provide their care.