POLRI DAERAH JAW JAWA TIMUR BIDANG KEDOKTERAN KEDOKTE RAN DAN KESEHATAN KESEHATAN RS BHA BH AYANGKARA ANGKAR A WAHYU WAHYU TUTUKO BOJONEGORO BOJONEGO RO
ANALISA KEJADIAN NYARIS CEDERA (KNC) DI RUMAH SAKIT BHAYANGKARA WAHYU TUTUKO BOJONEGORO
I.
DASAR
1. Rencana Rencana Kerja Ruma Ruma Sa!"# Ba$an%!ara Ba$an%!ara Wa$u Wa$u Tu#u!& Tu#u!& B&j&ne%&r& B&j&ne%&r& T.A. T.A. '(1) '. PERK PERKAP AP Ka*& Ka*&+r +r"" N&. N&. 11 Taun aun '(1 '(11 #en# #en#an an% % S#u! S#u!#u #urr Or%a Or%an" n",a ,a," ," Ruma Ruma Sa!" Sa!"## Ba$an%!ara. II.
MAKSUD DAN TUJUAN Ma!,u- -an #ujuan -"+a!u!ann$a ana+",a -ar" +a*&ran Keja-"an N$ar", "-era
/KN0 $a"#u un#u! menen#u!an a*a!a *er+u -"+a!u!an "ne,#"%a," +anju#an a#au RA / Root Root Cause Analysis0 Analysis0 -" Ruma Sa!"# Ba$an%!ara Wa$u Tu#u!& Tu#u!& B&j&ne%&r&.
III.
ANALISA In,"-e In,"-en n Keja-" Keja-"an an N$ar", N$ar", e-era e-era /KN0 /KN0 *er+u *er+u -"+a!u! -"+a!u!an an ana+", ana+",aa -" ,e2a2! ,e2a2!an an
!eja-"an KN ,e2an$a! 1 /,a#u0 !a,u, -" RS Ba$an%!ara Wa$u Tu#u!& B&j&ne%&r& -en%an n&mer !a,u, (341(4'(1). Kr&n&+&%" In,"-en5 *a-a ar" juma# #an%%a+ 3(6(76'(1) jam (7.3( ,ea2", ,enam8 #"2a #"2a #er-en%ar ,uara ,e*er#" 2en-a ja#u ,e#e+a -" ce! #ern$a#a *+a9&n -e*an ruan% Ba$an%!ara : Ja#u. 1. Analisa Dampak Klinis Dampak Klini!D"#a$a% K"pa#a&an!C onsequences Lee+ De,!r"*," &n#& De,!r"*," 1 Insignificant/No Harm T"-a! a-a ce-era Keru%"an !euan%an !ec"+ ' M"n&r Da*a# -"a#a," -en%an *er#&+&n%an *er#ama Keru%"an !euan%an ,e-an% 3 M&-era#e Ber!uran%n$a 9un%," m&r&#" m&r&#"!4, !4,en, en,&r" &r"!4* !4*,"! ,"!&+& &+&%", %", a#au a#au "n#e+e "n#e+e!#u !#ua+ a+ ,eca ,ecara ra *erma *ermane nen8 n8 $an% $an% #"-a #"-a! ! 2er 2eru2 u2un un%an %an -en%an *en$a!"#. Se# Se#"a* !a,u !a,u,, $an% $an% mem mem*er* *er*an anja jan% n% +ama ama *era;a#an. < Maj&r e-era +ua, Ke"+an%an Ke"+an%an 9un%," 9un%," u#ama *ermanen /m&#&r"!8 /m&#&r"!8 ,en, ,en,&r &r""!8 *,"!& ,"!&++&%", &%",88 "n#e+ n#e+e! e!#u #ua+ a+008 #"-a! -a! 2eru2un%an -en%an *en$a!"#. Keru%"an !euan%an 2e,ar. 2e,ar. : Seere4a#aa,#r&*"c4 Kema Ke ma#" #"an an $a $an% n% #" #"-a! -a! 2e 2er ru2 u2un un%an %an -e -en%a n%an n Sen#"ne+ *erja+anan *en$a!"#. Keru%"an !euan%an ,an%a# 2e,ar.
Ber-a,ar!an #a2e+ -am*a! !+"n", -" a#a, ma!a !a#e%&r" -am*a! !+"n", *a-a "n,"-en "n" a-a+a +ee+ 1 / Insignificant/no Insignificant/no harm0. harm0. Karena #"-a! a-a !eru%"an $an% -"#er"ma &+e *a,"en mau*un &+e ruma ,a!"#.
'. Ana+ Ana+", ",aa =re!ue =re!uen, n,"" KejaKeja-"a "an n
Lee+ 1 ' 3 < :
&n#& De,!r"*," Jaran% / >: #aun ,e!a+"0 Se,e!a+" /'6: #aun ,e!a+"0 Ka-an% ? !a-an% /16' #aun ,e!a+"0 Ser"n% /2e2era*a !a+" -a+am ,e#aun0 Ham*"r ,e+a+u /#erja-" #"a* m"n%%u42u+an0
Seja! -&!umen#a," "n,"-en -"mu+a"8 !a,u, ,e*er#" "n" a-a+a $an% *er#ama !a+"n$a8 ,e"n%%a -"%&+&n%!an *a-a +ee+ 18 !arena ma," ma,u! !a#e%&r" jaran%. 3. Ana+",a Risk Rating Number (Rangking Resiko)
Dam*a! K+"n",
RISK RATING NUMBER (RRN) RRN@ =re!uen," Dam*a! =re!uen," 3 1 ' < /Ka-an%6 /Jaran%0 /Se,e!a+"0 /Ser"n%0 !a-an%0
1 /N& arm0 ' /M"n&r0 3 /M&-era#e0 < /Maj&r0 : /a#a,#r&*"c0
: /Ham*"r ,e+a+u0
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Intepretasi Rangking Resiko
San%a# ren-a 16<
R"n%an :61(
Se-an% 1161:
Bera# 1)6':
Ha,"+ -ar" ana+",", risk rating number menunju!!an an%!a 1. Ha+ "n" -"#unju!!an -eraja# /10 !a+" 9re!uen," /10 men%a,"+!an 1 /risk rating number 1 ,an%a# ren-a0 <. Ana+",a R",! Gra-"n% Ma#r" Ha,"+ -ar" ana+",", -am*a! !+"n", -an 9re!uen," !eja-"an -"!&m2"na,"!an -" #a2+e Risk Grading Matrix un#u! menen#u!an #"n%!a# re,"!& -ar" "n,"-en $an% #erja-". Ha,"+ -am*a! !+"n", a-a -" !&+&m men-a#ar8 -an a,"+ 9re!uen," !eja-"an a-a -" !&+&m er#"ca+.
Dam*a! K+"n", In,"%n"9"can# M"n&r M&-era#e Maj&r Ham*"r ,e+a+u M&-era#e M&-era#e H"% E#reme /T"a* m"n%%u4 2u+an0 Ser"n% M&-era#e M&-era#e H"% E#reme /Be2era*a !a+" =re!uen,"
a#a,#r&*"c E#reme
E#reme
-a+am ,e#aun0 Ka-an%6!a-an% L&; /16' #aun ,e!a+"0 Se,e!a+" /'6: L&; #aun ,e!a+"0 Jaran% />: L&; #aun ,e!a+"0
M&-era#e
H"%
E#reme
E#reme
L&;
M&-era#e
H"%
E#reme
L&;
M&-era#e
H"%
E#reme
Dar" #a2e+ ruju!an risk grading matrrix -" a#a,8 ma!a -"-a*a#!an %ra-"n% re,"!& -ar" "n,"-en "n" a-a+a !&#a! 2"ru8 a#au low. Karena "n,"-en #er,e2u# mem"+"!" -am*a! !+"n", "n,"%n"9"can# -an 9re!uen," $an% jaran%. :. Ta2e+ A,,e,men Re,"!& N In,"-en #"*e In,"-en Dam*a! /D0 &
1.
=re!uen," /=0
1 ' 3 < : 1 ' 3 < In9ra,#ru!#ur 1 1 4Ban%unan4 2en-a +a"n #er*a,an% #e#a*
A#a* *+a9&n ja#u
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S!&r R",! Gra-"n% re,"! Ma#r" & D= L M H E 1 L
Ran%!"n% Re,"!&
1 /,an%a# ren-a0
). Rekapitulasi Berdasarkan Hasil RGM N' Tanal K"$aian
.
3(6(76 '(1)
Tip" Ini"n
S*+ Tip" Ini"n
In9ra,#ru!#ur4Ban%unan42en-a Ma,a+a +a"n #er*a,an% #e#a* A#a* -"ma!an ra$a*
J"ni Ini, "n (KTD! KNC!KTC !K-C) KN
Uni% %"#kai%
CK
Sp"iali, Risk Gradin ai g %"#kai% Matrix 6 L&;
. Rekapitulasi berdasarkan insiden N' Tanal .
3(6(76 '(1)
Nama -ai"n
Uni%
L'kai Sp"i/ik
Tn.S
Ruan% Luar Ruan% Ba$an%!ar" Ba$an%!ar" :
KTD
J"ni Ini"n KN KT 1
. Ana+",a T"*e In,"-en In,"-en "n" a-a+a Keja-"an N$ar", e-era !arena In9ra,#ru!#ur4Ban%unan42en-a +a"n #er*a,an% #e#a* 7. Ke,"m*u+an In,"-en 5 In9ra,#ru!#ur4Ban%unan42en-a +a"n #er*a,an% #e#a* R",! Gra-"n% Ma#r" 5 L&; T"*e In,"-en 5 Keja-"an N$ar", e-era /KN0
I0.
-ENUTU-
Dem"!"an Ana+",a Keja-"an N$ar", e-era /KN0 -" Ruma Sa!"# Ba$an%!ara Wa$u Tu#u!& B&j&ne%&r& "n" -"2ua# un#u! -"ja-"!an -a,ar a#au *e-&man -a+am
KP
*e+a!,anaan #u%a, ,ear"6ar" %una men"n%!a#!an mu#u *e+a$anan !e,ea#an -" Ruma Sa!"# Ba$an%!ara Wa$u Tu#u!& B&j&ne%&r&.
B&j&ne%&r&8
O!#&2er '(1)
KA KOMITE KPRS
BRECMANA A. P. S.=ARM8 APT PENATA NIP 17('(1'(11(11((1
