RUMAH SAKIT UMUM DAERAH WANGAYA KOTA DENPASAR KEPUTUSAN DIREKTUR RUMAH SAKIT UMUM DAERAH WANGAYA KOTA DENPASAR NOMOR ..... TAHUN 2014 T E N T A N G PEMBENTUKAN TIM PENINGKATAN MUTU DAN KESELAMATAN PASIEN RUMAH SAKIT DI RUMAH SAKIT UMUM DAERAH WANGAYA KOTA DENPASAR DIREKTUR RUMAH SAKIT UMUM DAERAH WANGAYA, Menimbn!
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. b#$ b#$ R%m# %m# S&i S&i'' Um%m Um%m De( De(# # Wn! n!) ) K*' *' Den+ Den+ ( ( e- e--% -% be(%+) %n'%& menin!&'&n &%-i' +e-)nn e%i en!n 'n( )n! i'en'%&n *-e# +e('%(n +e(%nn!/%nn!n )n! be(-&% n #(+n m)(&' b. b#$ b#$ -m -m (n!& (n!& memn' memn'% % n mem*'i mem*'i i i %+) %+) +enin! +enin!& &'n 'n m%'% n &ee-m'n +ien i R%m# S&i' Um%m De(# Wn!) K*' K*' Den+ Den+(( i+nn! i+nn! +e(-% iben'%& iben'%& Tim Penin! Penin!&' &'n n M%'% n Kee-m'n Kee-m'n Pien Pien )n! i -mn) 'e(i(i (i Uni' Penminn Penminn M%'%, Uni' Kee-m'n Pien n Uni' Mnemen Rii&* 3. b#$ be((& be((&n n +e('imbn!n eb!imn eb!imn im&% im&% #%(% n n b 'e(eb%', m& +e(-% i'e'+&n en!n Ke+%'%n Di(e&'%( R%m# S&i'
Men!in!'
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1. Unn! Unn! / Unn! N*m*( 1 T#%n T#%n 1552 1552 'en'n! 'en'n! Pemben'% Pemben'%&n &n K*'m K*'m) ) De(# Tin!&' Tin!&' II Den+( Den+( 6 Lemb(n Lemb(n Ne!( Re+%b-i& Re+%b-i& In*nei T#%n 1552 N*m*( 5, Tmb#n Lemb(n Ne!( Re+%b-i& In*nei N*m*( 7489 : 2. Un Unn! n! Un Unn! n! N*m* N*m*(( 25 '#% '#%n n 2004 2004 'e' 'e'n! n! P(& P(&'e 'e& & Ke*& e*&'e 'e( (n n 6Lemb(n Ne!( Re+%b-i& Re+%b-i& In*nei T#%n T#%n 2004 N*m*( 118, 'mb#n Lemb(n Ne!( Re+%b-i& In*nei N*m*( 4471 : 7. Unn! Unn! / Unn! Unn! N*m*( 72 T#%n T#%n 2004 'en'n! Peme(in Peme(in'# '#n n De(# De(# 6 Lemb(n Ne!( Re+%b-i& In*nei T#%n 2004 N*m*( 129, Tmb#n Lemb(n Lemb(n Ne!( Ne!( Re+%b-i& e+%b-i& In*nei In*nei N*m*( 447; :, eb!im eb!imn n 'e-# 'e-# i%b# bebe(+ &-i, 'e(i( en!n Unn! / Unn! N*m*( 12 T#%n 200< 'en'n! Pe(%b#n &e% ' Unn! / Unn! N*m*( 72 T#%n 2004 2004 'en' 'en'n n! ! Peme( eme(in in' '# #n n De( De(# # 6 Lemb Lemb( (n n Ne! Ne!( ( Re+%b e+%b-i -i& & In*nei T#%n 200< N*m*( 95, Tmb#n Lemb(n Ne!( Re+%b-i& In*nei N*m*( 4<44 : 4. Un Unn! n! = Un Unn! n! N*m* N*m*(( 29 T#%n #%n 2005 2005 'en' 'en'n n! ! Pe-) e-)n nn n P%b-i %b-i& & 6Lemb(n Ne!( Re+%b-i& In*nei T#%n 2005 N*m*( 112, Tmb#n Lemb(n Ne!( Re+%b-i& In*nei N*m*( 907<: 9. Unn! Unn! = Unn! Unn! n*m*( n*m*( 78 '#%n '#%n 2005 2005 'n!! 'n!!-- 1; 'en'n! 'en'n! Kee# Kee#' 'n n 6Lemb(n Ne!( Re+%b-i& In*nei '#%n 2005 n*m*( 144, Tmb#n Lemb(n Ne!( Re+%b-i& In*nei n*m*( 9087 : 8. Un Unn! n! = Un Unn! n! Re+%b e+%b-i -i& & In* In*ne nei i N*m* N*m*(( 44 T#%n #%n 2005 2005 'en' 'en'n n! ! R%m# S&i' 6 Lemb(n Ne!( Re+%b-i& In*nei T#%n 2005 N*m*( 197, Tmb#n Lemb(n Ne!( Re+%b-i& In*nei N*m*( 90;2 : ;. Ke+%'%n Ke+%'%n P(eien P(eien Re+%b-i& Re+%b-i& In*nei n*m*( 40 T#%n T#%n 2001 'n!!- 2; M(e' 2001 'en'n! Pe*mn Pe*mn Ke-emb!n n Pen!e-*-n R%m# R%m# S&i' De(#
5. Pe('%(n Pe('%(n Men'e(i Kee#'n Kee#'n N*m*( 250 250 > Men&e > Pe( Pe( > III > 200< 'en'n! Pe(e'%%n Tin&n Ke*&'e(n 10. Pe('%( e('%(n n Men' Men'e(i e(i Ne!( Ne!( Pen Pen) )!% !%n nn n A+( A+('%( '%( Ne! Ne!( ( N*m* N*m*(( 17 T#%n T#%n 2005 'en'n! Pe*mn Pe*mn Penin!&'n Penin!&'n K%-i' K%-i' Pe-)nn Pe-)nn P%b-i& en!n P('ii+i M)(&' 11. Pe( e('%( '%(n Men'e en'e((i Kee# ee#' ' n Re+%b e+%b--i& In* In*n nei ei N*m*( *m*( 18 1851 51 > Men&e> Pe(> ?III> 2011 Ten'n! Kee-m'n Pien 12. Ke+%'% e+%'%n n Men'e Men'e(i (i Kee Kee# #'n 'n Re+% Re+%b-i b-i& & In*ne In*nei i N*m*( N*m*( 5<7 5<7 > Men Ke Ke > SK > @I >1552 'en'n! Pe*mn O(!nii R%m# S&i' Um%m 17. Ke+%'% e+%'%n n Men'e Men'e(i (i Kee Kee# #'n 'n Re+% Re+%b-i b-i& & In*ne In*nei i N*m*( N*m*( 125 125 > Men& Men&e > SK > II > 200< 'en'n! S'n( Pe-)nn R%m# S&i' 14. Pe(' e('%( %(n n De( De(# # K*' K*' Den+ Den+ (( N*m* N*m*(( < T#%n #%n 200< 200< 'n! 'n!! !-- 24 Deembe( 200< 'en'n! O(!nii n T' Ke( Lemb! Te&ni De(# K*' Den+( 6 Lemb(n De(# K*' Den+( T#%n 200< N*m*( < : 19. Pe('%( e('%(n n WW-i& i&*' *' Den+ Den+ (( N*m*( N*m*( 9 T#% T#%n n 2012 2012 'en'n! 'en'n! Pe(% Pe(%b# b#n n ' Pe('%(n W-i&*' Den+( N*m*( 74 T#%n 200< 'en'n! U(in T%! T%! b'n P O(!nii O(!nii Lemb! Te&ni De(# K*' Den+( 6 Be(i' De(# K*' Den+( T#%n 2012 N*m*( 9 : 18. Pe(' e('%( %(n n W-i& -i&*' *' Den+ Den+ ( ( N*m* N*m*(( 77 T#%n #%n 2012 2012 'en' 'en'n n! ! T' ' Ke-*- e-*- R%m# %m# S&i' S&i' Um%m Um%m De( De(# # Wn!) n!) K*' Den+ Den+( ( 6 Be(i' Be(i' De(# K*' Den+( T#%n 2012 N*m*( 77 : 1;. Ke+%' e+%'% %n n WW-i& i&*' *' Den+ Den+ (( N*m*( N*m*( 58 T# T#%n %n 200< 200< 'n!! 'n!!-- 27 %-i %-i 200< 'en'n! 'en'n! Pene' Pene'+n +n Bn Bn Pe-) Pe-)nn nn R%m# S&i' S&i' Um%m De(# De(# Wn!) K*' Den+( eb!i Bn L)nn
MEMUTUSKAN "
Mene'+&n
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KESATU
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KEDUA
KETIGA
Memben'%& Tim Penin!&'n M%'% n Kee-m'n Pien R%m# S&i' Um%m De(# Wn!) K*' Den+( Memben'%& Un Uni' = Uni' ) )n! ''e e(m%& i i -m Ti Tim Penin!&'n M% M%'% n Kee- Kee-m' m'n n Pien Pien R%m# S&i' S&i' Um%m De(# De(# Wn!) n!) K*' K*' Den+(, )i'% Uni' Penminn M%'%, Uni' Kee-m'n Pien n Uni'
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Mene'+&n S'(%&'%( O(!nii n U(in T%! Tim Penin!&'n M%'% n Kee-m'n Pien R%m# S&i' Um%m De(# Wn!) K*'
KEEMPAT
Tim Penin!&'n M%'% n Kee-m'n Pien R%m# S&i' + R%m# S&i' Um%m De(# Wn!) K*' Den+( bee(' %(in '%!n) eb!imn 'e(3n'%m -m -m+i(n Ke+%'%n ini.
KELIMA
S%%nn An!!*', S'(%&'%( O(!nii n U(in T%! Tim Penin!&'n M%'% n Kee-m' ee-m'n n Pien ien eb!im eb!imn n im&% im&% -m -m i&'%m i&'%m &e'%, &e% n &e'i! 'e(3n'%m -m -m+i(n &e+%'%n ini
KEENAM
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Ke+%'%n ini be(-&% + 'n!!- i'e'+&n
KETUUH
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Men3b%' SK N*. 85 T#%n 2017 'en'n! Pe Pemben'%&n Uni' Pe Penminn M%'% M%'% n n SK N*. N*. 227 227 T#%n #%n 2017 2017 'en' 'en'n n! ! Pembe emben' n'%& %&n n K*mi' *mi'e e Kee-m'n Pien R%m# S&i'
Di'e'+&n i Den+( + 'n!!-, .... eb(%(i 2014 Di(e&'%( R%m# S&i' Um%m De(# Wn!) K*' Den+(,
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LAMPIRAN I KEPUTUSAN DIREKTUR DIREKTUR RUMAH SAKIT UMUM DAERAH DAERAH WANGAYA WANGAYA KOT KOTA A DENPASAR TANGGAL TANGGAL " .. eb(%(i eb(%(i 2014 2014 NOMOR NOMOR " .. T#%n #%n 2014 TENTANG TENTANG " PEMBENTUKAN PEMBENTUKAN TIM PENINGKA PENINGKATAN MUTU DAN KESELAMAT KESELAMATAN PASIEN RUMAH SAKIT DI RUMAH SAKIT UMUM DAERAH WANGAYA KOTA DENPASAR
STRUKTUR ORGANISASI TIM PENINGKATAN MUTU DAN KESELAMATAN PASIEN RUMAH SAKIT UMUM DAERAH WANGAYA WANGAYA KOTA KOTA DENPASAR
Di(e&'%(
Ke'% Tim Penin!&'n M%'% n Kee-m'n Pien
Se&(e'(i
Ke+- Uni' Kee-m'n Pien R%m# S&i'
Ke+- Uni' Penminn M%'%
K**(in'*( M%'% Mnemen
K**(in'*( M%'% K-ini&
K**(in'*( Ine'i!i
K**(in'*( Pe-+*(n
Ke+- Uni' Mnemen Rii&*
K**(in'*( K**(in'*( K**(in'*( K**(in'*( Rii&* Di&-' Min!/Min! In'-i>Uni'>B!in>Bin! P'ien' e')i*C3e(
Di(e&'%( R%m# S&i' Um%m De(# Wn!) K*' Den+(,
(. Se'i$'i H('$n, M.&e Pembin U'm M% NIP.159<110 NIP.159<110< < 15<412 2 001
LAMPIRAN II KEPUTUSAN KEPUTUS AN DIREKTUR RUMAH SAKIT UMUM DAERAH WANGAY WANGAYA A KOTA KOTA DENPASAR TANGGAL TANGGAL " .. eb(%(i eb(%(i 2014 NOMOR" .. T#%n 2014 TENTANG TENTANG " PEMBENTUKAN PEMBENTUKAN TIM PENINGKA PENINGKATAN MUTU DAN KESELAMAT KESELAMATAN PASIEN RUMAH SAKIT DI RUMAH SAKIT UMUM DAERAH WANGAYA KOTA DENPASAR
SUSUNAN TIM PENINGKATAN MUTU DAN KESELAMATAN PASIEN RUMAH SAKIT UMUM DAERAH WANGAYA WANGAYA KOTA KOTA DENPASAR
Ke'%
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Se&(e'(i
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DR. (. I W)n Bi&in S%()$n, S+.A 6K: N. A!%n! T(i Wi)*n* Sn'**, S.Ke+.
1.Uni' Penminn M%'% Ke+- Uni' Penminn M%'% K**(in'*( M%'% K-ini& K**(in'*( M%'% Mnemen 2. Uni' Kee-m'n Kee-m'n Pien Pien Ke+- Uni' Kee-m'n Pien K**(in'*( Ine'i!i K**(in'*( Pe-+*(n K**(in'*( Di&-' K**(in'*( P'ien' e') *C3e( 7. Uni' Mnemen Rii&* Rii&* Ke+- Uni' Mnemen
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N. Ni P%'% S(i W#)%ni, S.Ke+. N. A!%n! T(i Wi)*n* Sn'**, S.Ke+. Gee K(in Uin, SKM.
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S*$'%- M%#, ST. 1. Se-% Se-%(% (%# # Ke - - In' In'- ii
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LAMPIRAN III KEPUTUSAN DIREKTUR RUMAH SAKIT UMUM DAERAH WANGAYA KOTA DENPASAR TANGGAL TANGGAL " .. eb(%(i eb(%(i 2014 2014 NOMOR NOMOR " .. T#%n #%n 2014 TENTANG TENTANG " PEMBENTUKAN PEMBENTUKAN TIM PENINGKA PENINGKATAN MUTU DAN KESELAMAT KESELAMATAN PASIEN RUMAH SAKIT DI RUMAH SAKIT UMUM DAERAH WANGAYA KOTA DENPASAR
URAIAN TUGAS TIM PENINGKATAN MUTU DAN KESELAMATAN PASIEN RUMAH SAKIT UMUM DAERAH WANGAYA WANGAYA KOTA KOTA DENPASAR
1. Ke'% Ke'% Tim Penin!&'n Penin!&'n M%'% M%'% n Kee-m'n Kee-m'n Pien Pien mem+%n)i mem+%n)i '%! eb!i eb!i be(i&%' be(i&%' " . Mem'i&n Mem'i&n &en-n &en-n +e(en3nn +e(en3nn m%'% n +en!en-in +en!en-in m%'% n &ee-m'n &ee-m'n +ien be(i&%' 'e&ni& n -' -m me-&n&n &e!i'n 'e(eb%' b. Mem'i& Mem'i&n n 'e(-&nn 'e(-&nn) ) +e(bi&n +e(bi&n m%'% n &ee- &ee-m' m'n n +ien +ien me--%i me--%i &e!i' &e!i'n/ n/ &e!i'n *i-ii, i-i'i, n %i' )n! me-ib'&n +('ii+i +i#&/+i#& e%i &%n'bi-i' min!/ min! 3. Mem'i& Mem'i&n n 'e(-& 'e(-&nn) nn) ee&'ii' ee&'ii' mnemen mnemen (ii&* (ii&* %%n) %%n) &e!i'n &e!i'n +e-)nn +e-)nn n mneme mnemen n e#in!! e#in!! 'e($%% 'e($%% +en%(%nn +en%(%nn n!& (ii&* (ii&* n be(m+ be(m+& & &e+ &e+ +enin!&'n m%'% n &ee-m'n +ien . Mem'i&n Mem'i&n 'e(3i+'n) 'e(3i+'n) &*m%ni&i &*m%ni&i n #%b%n!n )n! bi& en!n +('ne( +('ne(/+('ne( /+('ne( 'e(&i' en!n &(ei'i m%'% n &ee-m'n +ien e. Me-&%&n Me-&%&n -ii -ii ' ' %n'%& mem'i&n mem'i&n &en-n &en-n in*(mi in*(mi +en3+in +en3+in ini&'*( ini&'*( m%'% n &ee-m'n +ien . Me- Me-& &n n& &n n +en +enm m+i +in! n!n n n n &**( **(in in ii en! en!n n +emb +embim imbi bin! n! &( &(ei' ei' ii n n +e-&n %(ei-n3e -m me$%%&n +emen%#n 'n( m%'% n &ee-m'n +ien )n! 'e-# i'e'+&n !. Men)%%n Men)%%n &ebi &ebi&n &n,, '('e!i '('e!i n +(*e%( +(*e%( i bin! bin! mnemen mnemen m%'% #. Men)%%n Men)%%n ini& ini&'*( '*( m%'% m%'% n &ee&ee-m' m'n n +ien +ien i. Men)%%n Men)%%n +(*!(m +(*!(m +enin!& +enin!&'n 'n m%'% m%'% n n &ee&ee-m' m'n n +ien +ien . . Memn'% n n men!e-%i men!e-%i e-%(%# +(*!(m +enin!&'n +enin!&'n m%'% n &ee-m'n &ee-m'n +ien &. Men*i-ii&n Men*i-ii&n #i- +en3+in +(*!(m +enin!&'n +enin!&'n m%'% n &ee-m'n &ee-m'n +ien +ien -. Men!&** Men!&**(in (ini& i&n n +e-&n +e-&nn n %i' %i' m%'% m%'% in'e(n in'e(n- - m. Men!&**(ini& Men!&**(ini&n n +en)%%nn (en3n (en3n n $- &e!i'n &e!i'n 'e(&i' 'e(&i' en!n &(ei'i &(ei'i m%'% n. Memi-i'i Memi-i'i +embimbin!n +embimbin!n in'e(nin'e(n- n e&'e(ne&'e(n- 'e(&i' 'e(&i' en!n en!n +e-&nn +e-&nn &(ei'i &(ei'i m%'% *. Memi-i'i Memi-i'i &e!i'n &e!i'n )n! 'e(&i' 'e(&i' en!n en!n in*i in*i m%'% bi& (i (i in'e(nin'e(n- m%+%n m%+%n e&'e(n- +. Me-&n&n Me-&n&n +en!%m+%-n +en!%m+%-n n n n-ii n-ii ' 'e(&i' en!n +en3+in +en3+in ini&'*( m%'% n &ee-m'n +ien F. Me-&n&n Me-&n&n &e!i'n &e!i'n &*n%-'i &*n%-'i 'e(#+ 'e(#+ e-%(%# e-%(%# %ni' &e( 'e(&i' en!n +e-&nn +enin!&'n m%'% n &ee-m'n +ien 2. Se&(e'(i Se&(e'(i Tim Penin!&'n Penin!&'n M%'% n n Kee-m'n Kee-m'n Pien Pien mem+%n)i mem+%n)i '%! eb!i eb!i be(i&%' be(i&%' " . Me-&n&n Me-&n&n &e!i'n &e!i'n mini'(i mini'(i +e-&nn +e-&nn +(*!(m +enin!&'n +enin!&'n m%'% n &ee-m'n +ien b. Men!%m+%Men!%m+%-&n &n n n men)im+n men)im+n en!n en!n bi& -+*( -+*(n n ' ini&' ini&'*( *( m%'% n &ee-m'n +ien i e-%(%# %ni' 3. Memb%' Memb%' $$- +e('em% +e('em%n> n> (+', (+', bi& bi& )n! (%'in (%'in m%+%n m%+%n inien'i inien'i- - . Men)%%n Men)%%n $$- (*ne (*ne &ee&ee-m m'n 'n +ien +ien &e &e %ni'/ %ni' %ni' e. Men)%% Men)%%n n $$- -ii -ii ' m%'% &-ini &-ini& & . Men)%%n Men)%%n -+*(n -+*(n inien inien e&'e( e&'e(nn- n in'e(n in'e(n-- e(' -+*(n -+*(n be(&- be(&- &e!i &e!i'n 'n Tim KPRS !. Men)%%n -+*(n '(i$%-n n '#%nn '#%nn e%i e%i +(*!(m +(*!(m +enin!&'n +enin!&'n m%'% n &ee-m'n +ien #. Me$&i-i Me$&i-i Ke'% Ke'% Tim Tim KPRS bi- bi- &e'% &e'% be(#- be(#-n!n n!n i. Men!&** Men!&**(in (ini( i( &e!i' &e!i'n n e-%(%# e-%(%# &**(i &**(in'* n'*(( i %ni' &ee&ee-m' m'n n +ien +ien n %ni' +enminn m%'% . . Men!&**(ini( Men!&**(ini( &e!i'n &e!i'n &*mi'e>'im &*mi'e>'im 'e(&i' 'e(&i' en!n +(*!(m +enin!&'n +enin!&'n m%'% m%'% n &ee-m'n +ien &. Me-&%&n Me-&%&n m*ni'*(in! m*ni'*(in! n e-%i &e!i'n &e!i'n n +(*!(m i &*mi'e>'im>%ni' &*mi'e>'im>%ni' 'e(&i' en!n +(*!(m +enin!&'n m%'% n &ee-m'n +ien UNIT PENAMINAN MUTU 1. Ke+- Ke+- Uni' Uni' Penmi Penmin n M%'% mem+%n)i mem+%n)i '%! '%! eb!i eb!i be(i&% be(i&%'' "
. Men)%%n Men)%%n &ebi &ebi&n &n n n '('e! '('e!ii mneme mnemen n m%'% b. Men)% Men)%%n %n +(*!( +(*!(m m ini& ini&'* '*(( m%'% m%'% 3. Me-&%&n Me-&%&n &**(ini &**(ini en!n %ni' %ni' 'e(&i' 'e(&i' -m -m +en)%%nn +en)%%nn +(*!(m +(*!(m +enminn +enminn m%'% -inn) . Me-&%&n Me-&%&n &**(ini &**(ini en!n SPI SPI -m -m +en)%%nn +en)%%nn '**- %i' m%'% in'e(n- in'e(n- e. Memn'% Memn'% +e-& +e-&n nn n e-%(%# e-%(%# +(*!( +(*!(m m +enmin +enminn n m%'%0 . Men!eMen!e-%i %i +e-&n +e-&nn n e-%(%# e-%(%# +(*! +(*!(m (m +en +enmin minn n m%'% m%'%
!. #. i. . &. -. m. n. *. +. F. (. .
Men)%%n Men)%%n -+*( -+*(n n #i#i- +en3 +en3+i +in n ini&' ini&'*( *( Men*i Men*i-i -ii& i&n n #i- +en3+ +en3+in in +(*!(m +(*!(m +enmi +enminn nn m%'% MemiMemi-i' i'ii 'in& 'in& -n%' -n%' #i#i- (e&*men (e&*meni i Men)%%n $$- be( be( &e!i'n &e!i'n &(ei'i &(ei'i ni*n- ni*n- Me-&%&n Me-&%&n &**(ini &**(ini 'e(&i' +en)%%nn (en3n &e!i'n &e!i'n &(ei'i &(ei'i ni*n- ni*n- MemiMemi-i' i'ii (+' '% '% +e('em%n +e('em%n 'e(& 'e(&i' i' +e-&n +e-&nn n &(ei' &(ei'i i ni*n- ni*n- Memi-i'i Memi-i'i +embimbin!n in'e(nin'e(n- n e&'e(ne&'e(n- 'e(&i' +e-&nn +e-&nn &(ei'i &(ei'i Me(-&%&n Me(-&%&n &**(ini &**(ini en!n 'im +'ien' +'ien' e') n %ni' 'e(&i' 'e(&i' -m -m +emb%'n RA RA n MEA Me(-&%&n Me(-&%&n &**(ini &**(ini en!n 'im 'im +'ien' +'ien' e') n %ni' %ni' 'e(&i' 'e(&i' en!n en!n +em,bimbin!n F%-i') n +'ien' e') Memi-i'i Memi-i'i &e!i'n &e!i'n 'e(&i' +en)e-en!!(n +en)e-en!!(n +en!embn!n in*i n n !%!% &e(n-i m%'% Memi-i'i Memi-i'i (+' n '% '% +e('em%n &**(ini &**(ini b%-nn b%-nn en!n i(e&i n %ni' 'e(&i' Me-&%&n Me-&%&n &**(ini &**(ini &e+ b!in>bin!>&*mi'e>%n b!in>bin!>&*mi'e>%ni' i' 'e(&i' 'e(&i' 'e(#+ 'e(#+ im+-emen'i im+-emen'i 'n( +e-)nn )n! be(*&% &e+ +ien n mnemen Men!#i Men!#i(i (i (+', (+', +e('em%n, +e('em%n, $*(&#*+ $*(&#*+ n '% '% emin( emin( 'e(&i' 'e(&i' +en!embn! +en!embn!n n m%'% &-ini& bi& in'e(n- m%+%n e&'e(n-
2. K**( K**(in'* in'*(( M%'% Pe-)n Pe-)nn n mem+%n)i mem+%n)i '%! '%! eb!i eb!i be(i&%' be(i&%' " . Memb%' Memb%' (en3n (en3n '('e!i '('e!i +(*!(m +(*!(m +en!em +en!embn! bn!n n m%'% &-ini& &-ini& b. Men)%%n Men)%%n +n% +n%n n +emn'% +emn'%n n ini& ini&'*( '*( m%'% m%'% &-ini& &-ini& 3. Memb%' Memb%' m'(i& m'(i& 'e&ni 'e&ni n me'*e-*!i me'*e-*!i +emn' +emn'%n %n ini& ini&'*( '*( m%'% &-ini& &-ini& . Men)%% Men)%%n n -' %&%( %&%( +emn'% +emn'%n n ini&' ini&'*( *( m%'% &-ini& &-ini& e. Be(&**(ini Be(&**(ini en!n %ni' %ni' 'e(&i' 'e(&i' -m -m +en)e-en!!( +en)e-en!!(n n +emn'%n +emn'%n ini&'*( ini&'*( m%'% m%'% &-ini& . Men!nMen!n-i i #i#i- +en3 +en3+i +in n ini& ini&'*( '*( m%'% &-ini& &-ini& !. Me-&%&n Me-&%&n &*m+(i &*m+(i #i#i- +emn'%n +emn'%n ini&'*( ini&'*( m%'% &-ini& e3( e3( +e(i*i3 +e(i*i3 en!n en!n 'n( ni*n- e(' (%m# &i' -in )n! eeni #. Memb%' Memb%' -+*(n -+*(n +e(i*i3 +e(i*i3 #i#i- +emn' +emn'%n %n ini& ini&'*( '*( m%'% &-ini& &-ini& i. Men)e-e Men)e-ei& i&n n n men)i*+& men)i*+&n n &e!i' &e!i'n n *i-i *i-iii in'e(nin'e(n- (%m# (%m# &i' 'en'n! 'en'n! +en3+in +en3+in ini&'*( m%'% &-ini& . Men)%%n b#n b#n (e&*meni (e&*meni 'e(#+ 'e(#+ +en3+in +en3+in #i#i- +emn'%n +emn'%n ini&'*( m%'% &-ini& &. Me(ni'(ib%i&n Me(ni'(ib%i&n b#n (e&*men (e&*meni i #i- +emn'%n ini&'*( m%'% &-ini& &e %ni' 'e(&i' -. Memb%' Memb%' (e&+ (e&+n n n -+*(nm -+*(nm e-% e-%i i 'in& 'in& -n%' -n%' (e&*men (e&*meni i (i (i %ni' 'e(&i' 'e(&i' m. M-&n&n M-&n&n &*m%ni&i &*m%ni&i e3( e3( in'e(n- n e&'e(ne&'e(n- 'en'n! +en3+in +en3+in +(*!(m +(*!(m PMKP &e+ %ni' &e( i -in!&%n!n in'e(n- n +i#& -%( me--%i %('>emi->'e-+*n n. Membn'% &**(ini &**(ini -m &e!i'n &e!i'n in'e(n- n e&'e(ne&'e(n- +(*!(m +(*!(m %ni' +enminn +enminn m%'% *. Men!#i(i (+', +e('em%n, $*(&#*+ n '% '% emin( emin( 'e(&i' 'e(&i' +en!embn!n m%'% &-ini& bi& in'e(n- m%+%n e&'e(n- (%m# &i' +. Men)%% Men)%%n n +n%n -i -ii i ' in'e(n in'e(n-- %% ini&' ini&'*( *( m%'% &-ini& &-ini& F. Memb%' Memb%' -' -' %&%( -i -ii i %% %% ini& ini&'*( '*( m%'% m%'% &-ini& &-ini& (. Men) Men)ee-en en!! !!( (& &n n &e!i e!i' 'n n -i -i i i #i #i-- +en3 +en3+ +i in n ini ini& &'* '*(( m%'% m%'% &-ini &-ini& & be(&**(ini en!n %ni' 'e(&i' . Me-&n&n Me-&n&n n-ii n-ii &*m+('i &*m+('i #i#i- -ii -ii in'e(nin'e(n- en!n ' ' %ni' %ni' 'e(&i' '. Memb%' Memb%' -+*(n -+*(n #i#i- -i -ii i in'e(n in'e(n-- %% %% ini&'* ini&'*(( m%'% &-ini& &-ini& %. Memb%' Memb%' +(*!(m +(*!(m in* in*ii n !%!% !%!% &en-i &en-i m%'% m%'% in'e(n- in'e(n- . Men!&**(ini& Men!&**(ini&n n +en)e-en!!(n +en)e-en!!(n +en!embn!n, in*i n !%!% !%!% &en-i &en-i m%'% m%'% $. Men!&**(ini& Men!&**(ini&n n +(*!(m +(*!(m +en)e!(n +en)e!(n n +e-'i#n !%!% &en-i &en-i m%'% . Men!&**(ini& Men!&**(ini&n n e-%(%# e-%(%# &e!i'n &e!i'n -*mb in*i in*i %% %% +en!embn!n +en!embn!n m%'% in'e(nin'e(nn e&'e(n- ). Memb%' Memb%' -+*(n -+*(n &e!i &e!i'n 'n +en!emb +en!embn!n n!n in*i in*i n n !%!% &en&en-ii m%'% . Me-&%&n Me-&%&n &**(ini &**(ini &e+ b!in>bin!>%ni' b!in>bin!>%ni' 'e(&i' 'e(&i' 'e(#+ 'e(#+ im+-emen'i im+-emen'i 'n( +e-)nn )n! be(*&% &e+ +ien 7. K**( K**(in'* in'*(( M%'% Mneme Mnemen n mem+%n)i mem+%n)i '%! '%! eb!i eb!i be(i&% be(i&%'' " . Memb%' Memb%' (en3n (en3n '('e! '('e!i i +(*!(m +(*!(m +en!emb +en!embn!n n!n m%'% mneme mnemen n b. Men)%% Men)%%n n +n%n +n%n +emn'% +emn'%n n ini&'*( ini&'*( m%'% m%'% mnemen mnemen 3. Memb%' Memb%' m'(i& m'(i& 'e&ni 'e&ni n me'*eme'*e-*!i *!i +emn'% +emn'%n n m%'% mnem mnemen en . Men)%% Men)%%n n -' %&%( %&%( +emn'% +emn'%n n ini&' ini&'*( *( m%'% mneme mnemen n e. Be(&**(ini Be(&**(ini en!n %ni' %ni' 'e(&i' 'e(&i' -m -m +en)e-en!!( +en)e-en!!(n n +emn'%n +emn'%n ini&'*( ini&'*( m%'% m%'% mnemen . Men!nMen!n-i i #i#i- +en3+ +en3+in in ini&' ini&'*( *( m%'% m%'% mnem mnemen en !. Memb%' Memb%' -+*(n -+*(n +e(i*i3 +e(i*i3 #i#i- +enn'% +enn'%n n ini&'*( ini&'*( m%'% mnemen mnemen #. Me-&%&n Me-&%&n &*m+(i &*m+(i #i#i- +emn'%n +emn'%n ini&'*( ini&'*( m%'% mnemen e3( +e(i*i& en!n 'n( ni*n- n (%m# &i' -in eeni
i.
Men)e-en Men)e-en!!( !!(& &n n n men)i+&n men)i+&n &e!i'n &e!i'n *i-i *i-ii i in'e(n in'e(n-(%m -(%m# # &i' 'en'n! 'en'n! +en3+in +en3+in ini&'*( m%'% mnemen . Men)%%n b#n b#n (e&*meni (e&*meni 'e(#+ 'e(#+ +en3+in +en3+in #i- +emn'%n ini&'*( m%'% mnemen &. Meni'(ib%i&n Meni'(ib%i&n b#n (e&*men (e&*meni i #i#i- +emn'%n +emn'%n ini&'*( ini&'*( m%'% m%'% mnemen mnemen &e &e %ni' 'e(&i'
-. Memb%' Memb%' (e&+ (e&+n n n -+*(n -+*(n e-% e-%ii 'in& 'in& -n%' (ee& (ee&*men *meni i (i (i %ni' 'e(&i' 'e(&i' m. Me-&n Me-&n& &n n &*m%ni& &*m%ni&i i e3( e3( in'e(nin'e(n- n e&'e(n e&'e(n- 'en'n! 'en'n! +en3+ +en3+in in +(*!(m +(*!(m +en!embn!n m%'% n &ee-m'n +ien &e+ %ni' &e( i -in!&%n!n RSUD Wn!) n +i#& -%( me--%i %(' 'e('%-i, emi- n 'e-e+*n n. Membn'% be(&**( be(&**(ini ini -m -m &e!i'n &e!i'n in'e(nin'e(n- n e&'e(ne&'e(n- +(*!(m +(*!(m Uni' Penminn Penminn M%'% *. Men!#i(i (+', +e('em%n, $*(&#*+ n '% '% emin( emin( 'e(&i' 'e(&i' +en!embn!n m%'% mnemen bi& in'e(n- m%+%n e&'e(n- (%m# &i' +. Men)i+&n Men)i+&n *&%men/*&%m *&%men/*&%men en )n! )n! i+e(-%&n i+e(-%&n 'e(&i' 'e(&i' +(*!(m +(*!(m &(ei'i &(ei'i F. Men)i+&n Men)i+&n b#n b#n &**(ini &**(ini en!n mnemen 'e(&i' +(*!(m &(ei' &(ei'i i (. Be(&**( Be(&**(in ini i en!n en!n %ni' %ni' 'e(& 'e(&i' i' +(*!(m +(*!(m &(e &(ei' i'i i . Me-&n Me-&n& &n n n-ii n-ii &ei+n &ei+n +en)e-en +en)e-en!!( !!(n n &(ei' &(ei'i i '. Men)%% Men)%%n n -n!&# -n!&# '('e!i '('e!i -m +en)e-e +en)e-en!! n!!(n (n +(*!(m +(*!(m &(ei' &(ei'i i %. Me-&n&n Me-&n&n &**(ini &**(ini e&'e(ne&'e(n- 'e(&i' 'e(&i' +(*e +(*e +en)e-en!!( +en)e-en!!(n n &(ei'i &(ei'i . Men)i+&n Men)i+&n be(b!i be(b!i ##- -m -m (+' '% +e('em%n +e('em%n 'e(&i' &e!i'n &e!i'n &(ei'i &(ei'i $. Be(&**(ini Be(&**(ini en!n en!n %ni' 'e(&i' 'e(&i' -m men!%m+%-&n men!%m+%-&n ' &e!i'n &e!i'n &(ei'i &(ei'i . Men)%%n Men)%%n -+*( -+*(n n e-% e-%ii &e!i' &e!i'n n &(ei' &(ei'i i ). Memb%' -+*(n &e!i'n &e!i'n Uni' Penminn Penminn M%'% M%'% e3( e3( %m%m, in'e(n- m%+%n e&'e(n- . Me-&%&n Me-&%&n &**(ini &**(ini &e+ b!in>bin!>&*mi'e>%n b!in>bin!>&*mi'e>%ni' i' 'e(&i' 'e(&i' 'e(#+ 'e(#+ im+-emen'i im+-emen'i 'n( +e-)nn )n! be(*&% &e+ mnemen UNIT KESELAMATAN PASIEN 1. Ke+- Ke+- Uni' Uni' Kee-m' Kee-m'n n Pien Pien mem+%n)i '%! eb!i eb!i be(i&%' " . Memb%' Memb%' &ebi &ebi& &n n 8 (n (n &ee&ee-m' m'n n +ien +ien b. Be('n!!%n! $b &e+ Di(e&'%( R%m# R%m# S&i' 'e(#+ +e-&nn +e-&nn &e!i'n &e!i'n &ee-m'n +ien (%m# &i' 3. Men)%%n &ebi&n &ebi&n 'e(&i' en!n +(*!(m &ee-m'n &ee-m'n +ien (%m# (%m# &i' &i' . Memb%' Memb%' +(*!(m +(*!(m &e( &e( &ee&ee-m' m'n n +ien +ien (%m# (%m# &i' &i' e. Men!&** Men!&**(in (ini& i&n n &e!i &e!i'n 'n Se&(e Se&(e'(i '(i' ' . Me(en3 Me(en3n& n&n n +e- +e-'i#n 'i#n n!!*' n!!*' K*mi'e KPRS !. Me-&%&n Me-&%&n &**(ini &**(ini en!n %ni' %ni' -in -in %n'%& me-&n&n me-&n&n +(*!(m KPRS #. Me-&%&n Me-&%&n m*ni'*(in! m*ni'*(in! n e-%i 'e(#+ 'e(#+ &e!i'n &e!i'n e-%(%# e-%(%# n!!*' KPRS n i. Membe(i& Membe(i&n n (e&*men (e&*meni i +eme3# +eme3#n n m-# m-# &ee-m &ee-m'n 'n +ien +ien &e+ &e+ Di(e&'%( Di(e&'%( R%m# R%m# S&i' %n'%& i'in&-n%'i. 2. K**(in **(in'* '*(( Ine Ine'i! 'i! ii " . Mene(im n men!n-i men!n-i &emb-i &emb-i e'i+ e'i+ &ein &ein '% '% inien inien )n! i-*(&n i-*(&n b. Men!%&n Men!%&n *-%i +en3e!#n m-# )n! i%&n i%&n &e+ &e+ &e'% &e'% K*mi'e K*mi'e KPRS 3. Me-&%&n Me-&%&n m*ni'*(in! m*ni'*(in! n n e-%i e-%i &e &e %ni' %ni' 'e(#+ 'e(#+ +e-&n +e-&nn n +(*!(m +(*!(m &ee-m'n +ien 'e(&i' en!n ine'i!i n . Memb%' -+*(n be(&- n -+*(n -+*(n %% %% 'en'n! &e!i'n &e!i'n bin! bin! ine'i!i. ine'i!i. 7. K**(in **(in'* '*(( Pe- Pe-+*( +*(n n " . Mene(im n men3'' men3'' e-%(%# e-%(%# ' &ein> &ein> inien inien )n! i-+*(&n i-+*(&n *-e# %ni' b. Men!e-*m Men!e-*m+*&& +*&&n n > men!&' men!&'!*(i !*(i&n &n eni eni -+*(n -+*(n &ein &ein )n! i'e(im i'e(im 3. Me-& Me-&%& %&n n m*ni'*(i m*ni'*(in! n! n e-% e-%i i 'e(# 'e(#+ + +e- +e-& &n nn n +(*!( +(*!(m m &ee&ee-m m' 'n n +ien 'e(&i' en!n ine'i!i n . Men)%%n Men)%%n -+*(n -+*(n be(&be(&- n %% 'en'n! 'en'n! &e!i' &e!i'n n bin! bin! +e-+*(n. +e-+*(n. 4. K**( **(in in' '*( *( Di& Di&- -'' . Men)%%n Men)%%n +(*! +(*!(m (m +e-' +e-'i#n i#n n!!*' n!!*' K*mi'e K*mi'e KPRS b. Men)%%n Men)%%n +(*!( +(*!(m m *(ien'i *(ien'i %n'%& +e!$i +e!$i b(% b(% n m#i$ m#i$ +(&'e& +(&'e& 3. Men)%%n Men)%%n +(*!( +(*!(m m *i-i *i-iii &ee-m &ee-m'n 'n +ien +ien %n'%& e-%(%# e-%(%# +e!$i +e!$i . Memb%' Memb%' $$- +e-'i# +e-'i#n n in'e( in'e(nn- e. Me-&%&n Me-&%&n m*ni'*(in! m*ni'*(in! n e-%i 'en'n! b%) b%) &ee-m' &ee-m'n n +ien + e-%(%# e-%(%# +e!$i n . Memb%' Memb%' -+*(n -+*(n be(& be(&- - n -+*( -+*(n n %% %% 'e(#+ 'e(#+ +e-& +e-&n nn n +(*!(m +(*!(m &ee-m'n +ien 'e(&i' en!n i&-' 9. K**( **(in in'* '*(( Patient safety ocer . Me-&n Me-&n& &n n 8 (n (n KeeKee-m' m'n n Pie Pien n b. Men*i-ii&n Men*i-ii&n 8 (n (n Kee-m'n Kee-m'n Pien Pien i %ni' min!/min! min!/min! 3. Memb%' Memb%' -+*( -+*(n n ini inien en Kee Kee-m -m'n 'n Pie Pien n . Me-&%&n Me-&%&n Ine'i!i ee(#n ee(#n inien inien Kee-m'n Kee-m'n Pien Pien e. Men3'' Men3'' inien inien Kee- Kee-m' m'n n Pi Pien en . Me-+*(&n Me-+*(&n em% inien Kee-m'n Kee-m'n Pien Pien )n! 'e(i &e K*mi'e KPRS RSUD RSUD Wn!) K*' Den+(
UNIT MANAEMEN RISIKO 1. Ke+- e+- Uni' Uni' Mn Mnem emen en Rii& Rii&* * 6 Risk Manager : . Men)%%n +(*!(m mnemen (ii&* (ii&* )n! &*ni'en &*ni'en en!n mii n n (en3n (en3n *(!nii, e(' memen%#i &eb%'%#n +ien, m)(&' n ' b. Me-&n Me-&n& &n n +(*e/+ +(*e/+(* (*e e mnemen mnemen (ii&* (ii&* en!n en!n men!!%n men!!%n&n &n +e*mn +e*mn +(&'e& 'e(&ini, 'n( +e-)nn mei&, &e+%'&n i-mi# n in*(mi -in be( be((& (&n n (n3n! (n3n!n n +(&'i& +(&'i& &-ini&, &-ini&, e(' e(' e%i e%i en!n en!n +(&'i& +(&'i& bini bini )n! e#' n (e-en en!n in*(mi 'e(&ini 3. Me-&n Me-&n& &n n +(*e/+( +(*e/+(*e *e Ien'i& Ien'i&i i (i (i (ii&* (ii&* . Me-&n&n Me-&n&n &*(in! &*(in! n mene'+&n mene'+&n +(i*(i' +(i*(i' (ii&*/(ii& (ii&*/(ii&* * i e-%(%# e-%(%# %ni' > in'-i in'-i > b!in > %ni' e. Me-&n&n Me-&n&n &**(ini &**(ini en!n en!n %ni' &ee-m'n &ee-m'n +ien -m -m #- +en)e-ii&n +en)e-ii&n KTD KTD . Me-&% Me-&%&n &n e-% e-%ii 'e(#+ 'e(#+ KN n n +(*e +(*e (ii&* (ii&* 'in!!i -inn) -inn) )n! )n! +' be(%b be(%b# # n be(&ib' 'e(in) &ein en'ine- !. Me-&n&n Me-&n&n &e!i'n &e!i'n MEA %n'%& %'% &ein &ein )n! )n! be(%%n! &e+ &e+ (ii&* (ii&* 'in!!i 'in!!i n en'ine- #. Me-&%&n Me-&%&n m*ni'*(in! m*ni'*(in! n n e-%i e-%i &e &e %ni'/%ni' %ni'/%ni' 'e(#+ 'e(#+ +e-&nn +e-&nn +(*!(m mnemen (ii&* (%m# &i' n mnemen (i #- -in )n! 'e(&i' i. Men)%%n Men)%%n -+*( -+*(n n be(&- be(&- n %% %% 'en'n! 'en'n! &e!i' &e!i'n n mnemen mnemen (ii& (ii&* * 'e(m%& 'e(m%& -+*(n MEA 2. K**( **(in in' '*( *( Rii Rii& &* . Me-&n&n Me-&n&n +(*e ien'i&i ien'i&i (ii&*/(i (ii&*/(ii&* i&* i min!/min! min!/min! %ni' b. Me-&n&n Me-&n&n n-ii ee(#n ee(#n 'e(#+ 'e(#+ (ii&*/(ii&* (ii&*/(ii&* )n! 3. Me-&%&n Me-&%&n m*ni'*(in! m*ni'*(in! n n e-%i e-%i +(*!(m +(*!(m (ii&* (ii&* i %ni' )n! meni 'n!!%n! $bn) . Me-+*(&n Me-+*(&n e3( be(&- #i- e-%i e-%i +(*!(m +(*!(m mnemen mnemen (ii&* (ii&* &e+ &e+ risk manager .
Di(e&'%( R%m# S&i' Um%m De(# Wn!) K*' Den+(,
(. Se'i$'i H('$n, M.&e Pembin U'm M% NIP.159<110 NIP.159<110< < 15<412 2 001