Formulir Laporan Insiden ke Tim KP di RS Rumah Sakit ................................... RAHASIA, TIDAK BOLEH DIFOTOCOPY, DIFOTOCOPY, DILAPORKAN MAXIMAL 2 x 2 2 !AM
LAPORAN INSIDEN "INTERNAL# I. DATA PASIEN Nama No MR mu-
$ T% A. Ruangan $ Kuti*a%+ $ & ' & ( )) $ &/0 1u*a% 0 1u*a% 3 0 tahu% 0 tahu% 3 ( tahu% ( tahu% 3 0( tahu% 0( tahu% 3 '& tahu% '& tahu% 3 4( tahu% 4( tahu% !5%i6 k5*ami% $ Laki/*aki P5-5m7ua% P5%a%++u%+ 1ia8a 7a6i5% $ P-i1a9i A6u-a%6i S:a6ta BP!S Lai%%8a "651utka%# Ta%++a* Ma6uk RS $ 0& !u*i !u*i 2&&; !am 2& '&
II. RINCIAN KEADIAN 0. Ta%++a* 9a%
2.I%6i95% $ K5*i-u 9a*am 75m15-ia% 9a-ah '. K->%>*>+i6 I%6i95% Ta%++a* Ta% ++a* 00 !u !u*i *i 2&& 2&&;; 7u 7uku* ku* &=.0(, T% A m5%9a7at t-a%6?u6i 9a-ah 9a-i 75tu+a6 -ua% -u a%+a +a%. %. Pu Puku ku** &=. &=.2( 2( 75 75tu tu+a6 +a6 Ba Ba%k %k Da Da-a -ah h m5 m5%5 %5*5 *57> 7>% % 75 75tu tu+a6 +a6-u -ua% a%+a +a% % u% u%tu tuk k m5%+h m5 %+h5%t 5%tika ika% % 75 75m15 m15-ia -ia% % 9a9a-ah ah k57 k57a9a a9a T% A kaka-5% 5%aa t5t5-@a9 @a9ii k5k k5k5*i 5*i-ua -ua% % 9a* 9a*am am 75m15-ia% 9a-ah >*5h 75tu+a6 Ba%k Da-ah k57a9a k5*ua-+a 7a6i5%. . !5%i6 I%6i95% $ K5@a9ia% N8a-i6 C595-a KNC (Near miss) K5@a9ia% Ti9ak 9iha-a7ka% KTD (Adverse Event) K5@a9ia% S5%ti%5* (Sentinel Event) Kejadian Tidak Cedera / KTC (. O-a%+ P5-tama Ya%+ M5*a7>-ka% I%6i95% Ka-8a:a% $ D>kt5- P5-a:at P5-a:at P5tu+a6 *ai%%8a Pa6i5% K5*ua-+a P5%9am7i%+ 7a6i5% P5%+u%@u%+
Lai%/*ai% ...........................................................................................!se"u#kan$
4. I%6i95% t5-@a9i 7a9a $ Pa6i5% Lai%/*ai% .............................................................................................................!se"u#kan$ Mi6 $ ka-8a:a% P5%+u%@u%+ P5%9am7i%+ K5*ua-+a 7a6i5%, *a7>- k5 K' RS. =. I%6i95% m5%8a%+kut 7a6i5% $ Pa6i5% -a:at i%a7 Pa6i5% -a:at @a*a% Pa6i5% D Lai%/*ai% .............................................................................................................!se"u#kan$ %. Tempa# Insiden L>ka6i k5@a9ia% $ Rua%+ Kuti*a%+..................................................................... !se"u#kan$ "T5m7at 7a6i5% 15-a9a#
). Insiden #er&adi pada pasien ' !sesuai kasus pen(aki# ) spesialisasi$ P5%8akit Da*am 9a% Su16756ia*i6a6i%8a A%ak 9a% Su16756ia*i6a6i%8a B59ah 9a% Su16756ia*i6a6i%8a O16t5t-i 8%5k>*>+i 9a% Su16756ia*i6a6i%8a THT 9a% Su16756ia*i6a6i%8a Mata 9a% Su16756ia*i6a6i%8a Sa-a? 9a% Su16756ia*i6a6i%8a A%a6t56i 9a% Su16756ia*i6a6i%8a Ku*it K5*ami% 9a% Su16756ia*i6a6i%8a !a%tu%+ 9a% Su16756ia*i6a6i%8a Pa-u 9a% Su16756ia*i6a6i%8a !i:a 9a% Su16756ia*i6a6i%8a Lai%/*ai% ...........................................................................................................!se"u#kan$ *+. ,ni# ) Depar#emen #erkai# (ang men(e"a"kan insiden %it k5-@a 75%851a1 $ Ba%kDa-ah ..................................................................!se"u#kan$ **. Aki"a# Insiden Ter-adap Pasien ' K5matia% C595-a I--55-6i15* C595-a B5-at C595-a R55-6i15* C595-a S59a%+ C595-a Ri%+a% Ti9ak a9a 595-a */. Tindakan (ang dilakukan segera se#ela- ke&adian0 dan -asiln(a '
P5-a:at -ua%+a% m5%+h5%tika% t-a%6?u6i 9a-ah 9a% m5*a7>-ka% k5@a9ia% t5-651ut k57a9a 9>kt5- 75%a%++u%+@a:a1, k5mu9ia% 9>kt5m5m15-ika% t5-a7i u%tuk m5%5+ah -5ak6i 8a%+ *51ih 15-at. *1. Tindakan dilakukan ole- ' Tim $ t5-9i-i 9a-i $ .................................................................................................................. D>kt5 P5-a:at P5tu+a6 *ai%%8a ..................................................................................................................... *2. Apaka- ke&adian (ang sama perna- #er&adi di ,ni# Ker&a lain3 Ya Ti9ak A7a1i*a 8a, i6i 1a+ia% 9i1a:ah i%i. Kapan 3 dan Langka- ) #indakan apa (ang #ela- diam"il pada ,ni# ker&a #erse"u# un#uk men4ega- #erulangn(a ke&adian (ang sama3 tahu% 8a%+ *a*u 9a% ti9ak a9a a%a*i6a k5@a9ia%
P5m1uat La7>-a% Pa-a? T+* La7>-
$ ................................... $ ................................... $ ...................................
P5%5-ima La7>-a% Pa-a? T+* t5-ima
5rading Risiko Ke&adian "Dii6i >*5h ata6a% 75*a7>-# $ 6IA, K,NIN5 V BIR, NB. G 7i*ih 6atu @a:a1a%
$ ................................... $ ................................... $ ...................................
MERA6
