MEMBANGUN BUDAYA KESELAMATAN PASIEN
BUDI SAMPURNA
SISTEMATIKA Pendahuluan Pengertian Budaya Keselamatan pasien Manfaat Budaya Keselamatan pasien Survei Keselamatan Pasien
Medical services
PROBABILITY, PROBABILIT Y, SEVERITY, AND EXPOSURE ? LEVEL OF RISK ? YES
ACCEPTABLE ?
NO
ACCEPT THE RISK CAN IT BE ELIMINATED ? ELIMINATE
CAN IT BE REDUCED ? REDUCED
CANCEL THE MISSION
SUDAHKAH SUATU PROSEDUR BETUL-BETUL AMAN? ADAKAH POSSIBLE POSSIBLE FAILURE FAILURE MODE?
KENALILAH PENYEBAB KECELAKAAN, BAIK DARI SISI FAKTOR MANUSIA MAUPUN FAKTOR SISTEM
MISHAP ANALYSIS MISHAP OCCURS RISK UNACCEPTABLE
LTA = LESS THAN ADEQUATE
RISK ACCEPTABLE
BUDAYA SAFETY
A safety culture culture is where staff within an organi org anisat sation ion have have a con consta stant nt and and active active awareness of the potential for things to go wrong. Both the staff and the organisation are able to ackno acknowledg wledge e mistak mistakes, es, learn from them them,, and take take act action ion to to put put thi things ngs rig right. ht. Budaya keselamatan adalah dimana staf dalam suatu organisasi memiliki kesadaran yg konstan dan aktif tentang hal yg potensial menimbulkan kesalahan. Baik staf maupun organisasi mampu membicarakan kesalahan, belajar dari kesalahan tsb, dan mengambil tindakan perbaikan
BUDAYA SAFETY
Being open and fair means sharing information openly openl y and free freely, ly, and fair fair treat treatment ment for staff staff when an inciden incidentt happens happens.. This This is vital for both the safety of patients and the well-being of those who wh o pr prov ovid ide e the their ir ca care re.. Bersikap terbuka dan adil / jujur berarti membagi informasi secara terbuka dan bebas, dan penanganan adil bagi staf bila insiden terjadi. Hal ini penting bagi keselamatan pasien dan ketenangan bagi pemberi layanan
BUDAYA SAFETY
The systems approach to safety acknowledges that the cause causes s of a patient patient safe safety ty incide incident nt cannott simply canno simply be linked linked to the the actions actions of the individual healthcare staff involved. All incidents are also also lin linked ked to to the syst system em in whic which h the individuals were working. Pendekatan sistem pada keselamatan menerangkan bahwa penyebab insiden keselamatan pasien tidak dapat dihubungkan dengan sederhana ke staf yang terlibat. Semua insiden berkaitan juga dengan sistem tempat orang itu bekerja
BUDAYA SAFETY
Changing values, beliefs and attitudes is not eas easy y . Deve Develop loping ing a saf safety ety cul cultur ture e in an an organisation needs strong leadership and carefu car efull pla planni nning ng and mon monito itorin ring. g.
Mengubah nilai-nilai, keyakinan, dan perilaku tidaklah mudah. Pengembangan budaya keselamatan dalam suatu organisasi memerlukan kepemimpinan yang kuat dan perencanaan & pemantauan yang cermat
BUDAYA SAFETY
It is vital that not only clinical staff but all those who work in organisations, as well as patients and carers, ask themselves how they can help to improve the safety of patients. Perubahan nilai, keyakinan dan perilaku tersebut penting bukan hanya bagi staf, melainkan juga semua orang yang bekerja di rumah sakit tersebut, serta pasien dan keluarganya. Tanyakan apa yang bisa mereka bantu untuk meningkatkan keselamatan pasien
KOMPONEN Penjelasan / pemahaman tentang aktivitas 1) acknowledgment of the high risk, error organisasi yang bersifat risiko tinggi dan rentan prone nature of an organization's activities, kesalahan
2) blame-free environment where Lingkungan yang sehingga individuals arebebas-menyalahkan, able to report errors or close orang melapor kesalahan tanpa callsdapat without punishment, penghukuman 3) expectation of collaboration across ranks to seekkerjasama solutionslintas to vulnerabilities, Harapan tingkatan untuk and mencari solusi atas vulnerabilitas 4) willingness on the part of the organization to direct to address Kemauan organisasi untukresources mengarahkan sumber safety concerns. daya untuk kepentingan keselamatan
Compon Com ponent ents s of a Cult Culture ure of of Saf Safety ety • Commitme ommitment nt to safe safety ty articula articulate ted d at at the highe highest st leve levels ls of the organiza organiz atio tion n and translated translated into i nto share shared d va values, lues, be beliefs, liefs, and and behavi beha vioral oral norms nor ms at all all leve levels ls.. • Nece cessa ssary ry re r esources, ince incentives, ntives, and rewards rewards provided by the organiz orga niza ation to allow allow this commitment commitment to occur. • Safe fety ty is i s valued valued as as the primary primary priority pr iority,, eve ven n at at the expe xpense nse of “ produ production” ction” or “ efficie fficiency” ncy” ; personn personne el are re rewa warde rded d for erring erring on on the side of safe safety ty eve even n if the they y turn out o ut to be wrong. • Communication betwe betwee en workers and and across across orga organiz niza ationa tionall le leve vels ls is freque frequent nt and candid. • Unsa nsafe fe acts are are ra rare re de despite spite high leve levels ls of productio production. n. • The here re is an an openness openness about errors errors and proble pro blems; ms; the they y are re reporte ported d when they they do occur oc cur.. • Orga rganiz niza ationa tionall learning learning is i s value valued; d; the response response to a problem focuses on improving sy ste stem m performance performance ra rathe therr than than on indivi dua duall blame. Source: Singer SJ, Gaba DM, Geppert Geppert JJ, et al. The culture culture of safety: results results of an organization-wide organization-wide survey surv ey in 15 California California hosp hospitals itals.. Qual Saf Health Care 2003 Apr;12(2):112-8. Reproduced with permission from the BMJ Publishing Group.
BLAMING vs SAFETY
BLAMING: A NAL ANA L ISIS BERA B ERAK K HIR PADA PA DA HUMA HUMAN N FACTORS FA CTORS TIND NDA A K A N: MENYAL MENYALA A HKA HKAN N DA DA N MENG ME NGHU HUK K UM TI MENGH MEN GHUKUM UKUM (LESS) (L ESS) REWA REWA RD AND A ND (MORE) (MORE) PUNISHME PUNISHMENT NT SIK K A P: SEMB SEMB UNY NYIKA IKAN N KESALA KESAL A HA N SI
SAFETY:
REPORTING REPORT ING,, ANA A NAL L YSI YSIS, S, LEA L EARN RNING ING,, (MORE)) REWARD (MORE REWA RD AND A ND (LESS) (L ESS) PUNISHME PUNISHMENT NT TINDA TIND A K A N: CARI UPAYA UPAYA PE PENC NCEG EGA A HAN S IK AP: BER BERLOM BERBUAT BUAT BA B A IK DAN SIK SI B ERLOMB LOMB A BER MENC ME NCEG EGA A H YG YG BURUK BURUK (BUD (B UDA A YA BELA B ELAJ J A R)
BLAMING ?
SUPPORTING?
SIKAP RUMAH SAKIT
Past stik ika an RS memil memilik ikii ke kebi bijaka jakan n yg menjaba menja bark rka an apa apa yg ha h aru rus s dil d ila aku kuka kan n staf s taf segera sege ra sete setell ah terj terja adi insid ins ide en, baga bagaim ima ana langk la ngka ah pe pengu ngumpu mpula lan n fa fakt kta a ha haru rus s di dila lakuk kuka an & duku d ukunga ngan n apa ya yang ng ha haru rus s dib d ibe eri rika kan n kepa ke pada da st sta af, pa pasi sie en - ke kelu lua arg rga a Past stik ika an RS memil memilik ikii ke kebi bijaka jakan n yg menj me nja aba bark rka an pe pera ran n & akun kunta tabi bili lita tas s in indi divi vidual dual bilama bi lamana na ada ada in insi siden den Tum umbu buhk hka an bu buda daya ya pelapor pelapora an & be belaja lajarr da dari ri insi in side den n ya y ang terja terjadi di di RS. Lakukan Laku kan asesm asesme en denga deng an menggu meng gunaka nakan n surve sur veii pe peni nila laia ian n KP KKP RS
SIKAP STAF DALAM TIM
Pas t i k an re r ek an se s ek er j a an d a m er as a mamp ma mpu u unt u ntuk uk be berb rbic ica ara meng menge ena naii kepedu kepe duli lia an me mereka reka & be berani rani me mela lapo pork rka an b il ila am ana ad a in ins s id ide en Demo mons nstr tra asi sikan kan kepa kepada da ti tim m and anda a uk ukur ura an yang dip d ipa akai di RS and nda a ut utk k me m ema mast stik ika an semua lapor lapora an dib d ibua uatt se s ecara te terr bu buka ka & terj te rja adi pr pros ose es pembe pembela lajara jaran n serta pelaks pela ksa ana naa an tin t indaka dakan n / so solu lusi si yg te tepa patt KKP RS
TERBUKA DAN JUJUR
staff are open about incidents they have been involved in; staff sta ff and org organi anisat sation ions s are accountable for their actions; staff feel able to talk to their colleagues and superiors about any incident; orga or gani nisa sati tion ons s ar are e open with patients, the public and staff when staff when things have gone wrong, and explain what lessons will be learned; staff are treated fairly and supported when an incident happens. NHS
Being open and fair does not mean an absence of accountability. Accountability for patient safety means means being open with patients, explaining the actions taken and providing assurance that lessons will be learned. NHS
TERBUKA DAN JUJUR SINGKIRKAN MITOS-MITOS: perfecti ction on myt myth h: the perfe bila orang bekerja keras maka mereka tidak akan membuat “errors” the puni punishme shment nt myth my th : bila kita menghukum orang yang melakukan “errors” “err ors” maka akan sema semakin kin sedik sedikit it pembu pembuat at “errors”, atau bahwa tindakan pendisiplinan dapat memperbaiki melalui channelling atau meningkatkan motivasi. NHS
Penanganan Insiden Staff harus sama persepsinya tentang insiden Staff harus tahu apa yang harus dilakukan bila menemui insiden: mencatat, melapor, dianalisis, memperoleh feed-back, belajar dan mencegah pengulangan Staff harus akuntabel dan tahu bagaimana pendekatan sistem dan personil
RESOLUTION OF ERROR NEGLECT / USED WRONG PROCEDURE
MENGAPA BUDAYA SAFETY? Bukti di industri lain menunjukkan bahwa budaya organisasi yang berorientasi ke keselamatan dan sikap karyawan yang berani bicara tentang terjadinya kesalahan telah meningkatkan keselamatan Di Rumah Sakit Wimmera - Australia:
Penurunan Adverse Events Pd pasien rawat inap : 1,35% - 0,74% Pd pasien IGD : 3,26% - 0,48%
MANFAAT BUDAYA SAFETY
a potential reduction in the recurrence and in the the sever severity ity of pati patient ent saf safety ety inc incide idents nts through increased reporting and organisational learning; Potensi mengurangi angka kejadian dan keparahan kejadian patient safety melalui peningkatan pelaporan dan pembelajaran organisasi
MANFAAT BUDAYA SAFETY
a reduction in the physical and psychological harm patients can suffer because people are more aware of patient safety saf ety con concep cepts, ts, are work working ing to prev prevent ent errors and are speaking up when things go wrong; Pengurangan derita fisik dan psikologis pasien, karena orang makin sadar tentang konsep patient safety akan bekerja mencegah kesalahan dan berbicara bila terjadi kesalahan
MANFAAT BUDAYA SAFETY
a lower number of staff suffering from distre dis tress, ss, guil guilt, t, sham shame, e, loss loss of con confid fidenc ence e and loss of morale because fewer incidents are occurring; Penurunan jumlah staf yang menderita tertekan, merasa bersalah, malu, kehilangan percaya diri, dan kehilangan keberanian mental, karena berkurangnya insiden yang terjadi
MANFAAT BUDAYA SAFETY
an improvement in waiting times for treatm tre atment ent thr throug ough h a high higher er tur turnov nover er of of patients. This is because patients who experie exp erience nce a safet safety y inc inciden identt requ require, ire, on average, an extra seven to eight days in hospit hos pital al ove overr and and abov above e the the tim time e thei theirr treatment would normally require ; Peningkata Peningkatan n “turnover “turnover”” pasien, pasien, mengingat mengingat pasien yg terkena insiden umumnya membutuhkan perawatan 7-8 hari lebih dari masa rawat normal
MANFAAT BUDAYA SAFETY a reduction in the costs incurred for treatment and extra therapy; a reduction in resources required for managing complaints and claims;
Pengurangan biaya untuk pengobatan / penatalaksanaan ekstra akibat insiden Pengurangan kebutuhan sumber daya untuk menangani komplain dan klaim
MANFAAT BUDAYA SAFETY
a decrease in wider financial and social costs cos ts inc incurr urred ed thr throug ough h pati patient ent saf safety ety incidents including lost work time and disability benefits. Penurunan biaya finansial dan sosial yang diperlukan untuk menangani insiden patient safety, termasuk kehilangan jam kerja dan pembayaran kecacatan
BAGAIMANA MEMULAI PENERAPAN BUDAYA KESELAMATAN PASIEN?
MULAILAH DENGAN SURVEI TENTANG ISU :
Bagaimana kemampuan managemen senior melihat ke depan dan berkomitmen ke arah keselamatan Bagaimana komunikasi antara staf dengan manager
TENTANG ISU:
Bagaimana sikap dan perilaku dalam melaporkan suatu kejadian, blaming dan penghukumannya Bagaimana faktor-faktor dalam lingkungan kerja mempengaruhi kinerja, seperti kelelahan, pemecahan perhatian, desain peralatan dan ketersediaan/kesiapan alat.
TOOLS UNTUK SURVEI
TYPOLOGY: Checklist for Assessing Institutional Resilience (CAIR ) Manchester Patient Safety Assessment Tool20 (MaPSaT) (AHA) and Veterans Advancing Health in America (AHA) Health Association (VHA): Strategies for Leadership. An Organisational Approach to Patient Safety
DIMENSIONAL:
Safety Attitudes Questionnaire (SAQ) Stanford Patient Safety Centre of Inquiry Culture Survey
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I. B ac k g r o u n d Var i ab l es A. What is your primary work area or unit in this hospital? H1. How long have you worked in this hospital? H2. How long have you worked in your current hospital work area/unit? H3. Typically, how many hours per week do you work in this hospital? H4. What is your staff position in this hospital? H5. In your staff position, do you typically have direct interaction or contact with patients? H6. How long have you worked in your current specialty or profession?
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II. Outcome measures
Frequency vent Re Repo port rtin ing g r eque qu ency nc y of of E Event
Ov er alll l P er c ep ti tio o ns Safety Pe ns o off Sa
Pat i en t Saf et y Gr ad e
Num umber ber of o f Eve vent nts s Repo porr te ted d
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Ovvera er al l Pe Per c ep ti tio o n s of o f Sa Safety fety:: veral A15. Patient safety is never sacrificed Keselamatan pasien tidak pernah dikorbankan untukto get more work done. memperbanyak pekerjaan yang bisa dikerjakan
A18. Our procedures and systems are good Prosedur dan sistem kita adalah bagus dalam mencegah at preventing errors from happening. terjadinya kesalahan A10r. It is just by chance that more serious mistakes don’t happen around here. (reverse worded) Hanyalah suatu kebetulan bahwa kesalahan yang lebih A17r. patient safety problems in this serius ser ius tid tidak ak terja teWe rjadi dihave disinii (ne disin (neg) g) unit (reverse worded)
Kita memili memiliki ki masalah masalah kesela keselamatan matan pasien pasien di di unit ini (neg) Reliability of this dimension—Cronbach’s alpha (4 items) = .74
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III. Safe fety u l tu tur men f ety ty C Cu t ur e Di me m en s i o n s (Un i t l ev el )
•Harapan tindakan supervisor dan upe edan rvis rv isor or//ma manage nager expe ect cta amanajer tion ti ons s &dalam actio act ions ns Sup mana gerr exp mempromosikan promoti prom oting ng keselamatan safety safe ty pro moting Organizational Learning —Continuous •Pemb •Pembelajar elajaran an organi organisasi sasi – perbai perbaikan kan kontin kontinyu yu
improvement •Kerjasama tim di Wit RSithi Teamw mwor ork k W hin n Hos Hospi pital tal Uni Units ts •Keterbukaan dalam berkomunikasi Communication Openness Feedback and nd Com ommu munic nica ati tion on Ab About out rror or ommun munication ication Abo ut Err •Umpan balik danakomunikasi tentang Kesalahan spon onse se To To Error Err or Nonpunitive Resp •Tanggapan yang tidak menghukum terhadap kesalahan Staffing •Staff ospi pital tal Ma Mana nage gement ment S uppo up port rtt fo forr Pati tie ent Hos Supp Suppor ort Safety RS mendukung Keselamatan Pasien •Manajemen
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Sup upe erv rvis isor or//mana manage gerr e exp xpe ect cta ati tion ons s & act actio ions ns manager promoti pro moting ng safe safety ty prom oting B1. My supervisor/manager says a good word when Supervisor / Manajer: he/she sees a job done according to established safety procedures. Memujipatient bila staf melakukan prosedur PS B2. My supervisor/manager seriously considers staff suggestions forusulan improving patientpeningkatan safety. Mempertimbangkan staf untuk PS B3r. Whenever pressure builds up, my supervisor/manager Memerintahkan percepatan kerja dengan melakukan wants us to work faster, even if it means taking jalan pintas shortcuts. (neg) (reverse worded) B4r. My supervisor/manager overlooks patient safety Tidak memperhatikan masalah PSand yg over. sudah(reverse terjadi problems that happen over berulang (neg) worded) Reliability of this dimension —Cronbach’s alpha (4 items) = .75
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Teamw mwor ork k Wit ithi hin n Hos ospi pita tall Uni nits ts Orang People saling mesupport mbantu done i unitanother ini A1. in this unit. Bila terWhen dapat pa eklot erjaof anwork banyaneeds k yg meto mbbe utudone hkan quickly, A3. diseleswe aikawork n secetogether patnya, kitas a ba ekteam erja beto rsaget ma the dalawork m satu done. tim ti m un untu tuk k men enye yele les sai aik kan anny nya a A4. In this unit, people treat each other with Dal ala am unit ini orang memperlakukan or ora ang lain dengan respect. hormat A11. When one area in this unit gets really busy, Bila salothers ah satu help area d i unit ini sibuk, maka yang lain akan out. membantunya
Reliability of this dimension—Cronbach’s alpha (4 items) = .83
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IV. Safe fety u l tu tur men f ety ty C Cu t ur e Di me m en s i o n s (Hospital -wide) Teamw mwor ork k Acro Ac ross ss Hos ospi pita tall Uni Units ts ospi pita tall Ha Hand ndof offs fs & Tra Trans nsit itio ions ns Hos
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Teamw mwork orkk Ac Acros ross s Hospita Hospit al U nits ni ts mwor A cros Acr oss Hospit Hosp ita Units
kerjasama yg baikamong antar unit yg F4. Terdapat There is good cooperation hospital harus bekerjasama units that need to work together. F10. Unit-unit Hospital bekerja units work well together to provide bersama untuk memberi the bestterbaik care forkepada patients. layanan pasien F2r. Unit-unit Hospital tidak units bekerjasama do not coordinate with satu well sama lain each other. (reverse worded) (neg) F6r. It is often unpleasant to work with staff from Sangat tidak menyebangkan other hospital units. (reverse bekerja worded) dengan staf dari unit lain (neg) Reliability of this dimension—Cronbach’s alpha (4 items) = .8
MANFAAT SURVEI Suatu organisasi perlu mengetahui budayanya yg sekarang sebelum bisa mengubah budaya tersebut Mengubah sikap dan perilaku itu sulit dan lama, perlu pemahaman tentang keselamatan pasien dan pendekatan sistem pada “errors” dan “incidents” Leadership penting dalam membentuk “value” dan “belief ” dalam budaya
L EVEL OF MATURIT MA TURITY Y WITH WITH RESPECT RESPECT MATURI TY TO A SA SAFET FETY Y CUL CUL TUR TURE E
Why Why waste waste our our time time On On safety? safety?
We do Something when we Have an incident
We We have have systems systems in in Place Place to to Manage Manage all all Like Like risks risks
We We are are always always On a lert fo On alert alert for for r R isk s that tha th at Risks isks Might Might emerge emerge
Risk Risk management management Is aan in tegral Is an ann integral i ntegral int egral P art oof f Part Pa rt of Everything Everything That Tha w Thattt we Tha wee do we do
SELANJUTNYA BAGAIMANA?
Langkah-langkah 1. Assess the culture of safety. 2. Provide science-of-safety education. 3. Identify safety concerns. 4. Establish senior leader partnerships with units. 5. Learn from one defect per month. 6. Re-assess (re-measure) the culture of safety. Membangun budaya adalah suatu siklus yg tak henti henti
ACTION A CTION RECOMMENDATIONS RECOMMENDA TIONS Seek leadership support for the creation of a culture cultu re of safet safety y throug throughout hout the orga organizat nization. ion. Suppor Sup portt can be gaine gained d by provi providin ding g data data demonstr demo nstrating ating that comm communica unication tion probl problems ems are major cause causes s of medic medical al erro errors rs and and inform information ation on how teamwo teamwork rk failur failures es lead to malpra malpractic ctice e claims claims and by by sharing sharing succ success ess stori stories es of facil facilities ities that have affe affected cted patie patient nt safe safety ty by impr improving oving safet safety y culture.
ACTION A CTION RECOMMENDA RECOMMENDATIONS TIONS Partner with clinicians and managers in conducting an assessment of the existing safety climate in the organization. Appoint a project team, accountable to a senior executive, to carry out the assessment using surveys, interviews, or other techniques. Based on survey findings, formulate and execute an actio action n plan to improv improve e the cultu culture re of of safety. safety. Establish Estab lish real realistic istic meas measures ures to gauge the effect eff ective ivenes ness s of of act action ion pla plans. ns.
ACTION A CTION RECOMMENDATIONS RECOMMENDA TIONS
Provide safety science education to frontl fro ntline ine staff staff,, man manage agers, rs, and and physi physician cians. s. Includ Inc lude e teamw teamwork ork tra trainin ining g and edu educat cation ion in communication techniques. Incorporate safety culture initiatives into the over overall all org organi anizat zationa ionall patient patient saf safety ety plan. pla n. Ensur Ensure e that that patient patient saf safety ety init initiat iatives ives,, action act ion plans plans,, and and resul results ts of of int interve erventi ntions ons to improve safety are periodically reported to the board of directors.
ACTION A CTION RECOMMENDA RECOMMENDATIONS TIONS • Esta Establish blish a nonpunit nonpunitive ive system system for repor reporting ting errors, erro rs, even events, ts, and near misse misses. s. Consi Consider der implement imple menting ing a rewar reward-bas d-based ed report reporting ing system system,, and ensu ensure re timely timely feed feedback back to staff staff on how how reports repo rts are used to impr improve ove patie patient nt safe safety. ty. • Ensur Ensure e that that disclo disclosure sure polic policies ies are are in in keeping keeping with curr current ent regul regulation ations s and and stand standards. ards. Work toward towa rd using discl disclosur osure e with with apology apology as a claim claim-avoi av oida danc nce e st stra rate tegy gy..
ACTION A CTION RECOM RECOMMENDA MENDATIONS TIONS • Sha Share re infor informat mation ion on impro improvem vement ents s and and succes suc cesses ses bas based ed on saf safety ety cult culture ure change cha nges s to to main maintai tain n enth enthusi usiasm asm for participation and support. Communicate plans to address areas still in need of improv imp roveme ement nt and oth other er oppo opportu rtunit nities ies to enhance patient safety.
Pengalaman VHA
The Veterans Health Administration (VHA) has implemented a multifaceted safety initiative, i nitiative, which was designed to build a culture of safety and address system failures. The approach consists of 4 major elements:
1) partnering with other safety-related organizations and affiliates to demonstrate a public commitment by leadership, 2) establishing centers to direct safety efforts, 3) improving reporting systems, and 4) providing incentives to health care team members and division leaders. These tactics are detailed below
Pengalaman SMUH South Manchester University Hospital
Membangun sistem pelaporan insiden yang berbasis web bagi ujung tombak Bila laporan dimasukkan, sistem langsung mengirim email ke Manajemen RS merawat inap 69.000 pasien/tahun Expected AE: 7.000 / tahun Setelah 3 tahun sistem dibangun, laporan sudah mencapai 4.500 / tahun 3-7% anonim, dirangsang utk pakai nama
Pengalaman SMUH South Manchester University Hospital
Penjelasan tentang hubungan antara Pelaporan dengan Pendisiplinan Penjelasan tentang hubungan antara Pelaporan dan pembelajaran Pelatihan dilakukan di tempat Informasi dalam web: clinical risk, medical alert, archived safety materials, patient safety newsletter
OSF St. Joseph Medical Center, in Bloomington, Ill.
Membolehkan juga pelaporan bersifat informal oleh staf keperawatan, ahli farmasi, laboratorium dll, melalui: Briefing saat pergantian shift jaga Ronde rutin oleh manajemen Telepon hotline
Krause et al Di luar bidang kedokteran: safety assessments, steering committee formation, development of checklists of well-specified critical behaviors related to safety observer training regarding the critical behaviors, observation and feedback
FAKTA
Dengan sistem patient Safety, Sentara Norfolk General Hospital: 84 % pengurangan Pneumonia yg berkaitan dg ventilator dari 2001 s/d Juni 2004 Dengan Tim Tanggap Cepat di Missouri Baptist Medical Center telah menurunkan 60 % penurunan panggilan darurat henti nafas dan krisis serupa dan penurunan 15% henti jantung. Johns Hopkins Hospital mengalami peningkatan 49 - 91 % proporsi pelaporan staf ICU tentang iklim safety dan menghilangkan kasus infeksi pembuluh darah akibat kateterisasi, mencegah 8 kematian dan berhemat $2 juta pertahun. Kasus adverse drug events menurun 91 percent di OSF St. Joseph Medical Center.
KATA AKHIR Keselamatan Pasien di Rumah Sakit hanya dapat dicapai dengan membangun budaya yang berorientasikan kepada keselamatan pasien Budaya keselamatan pasien harus dipahami, dihayati dan diamalkan oleh seluruh unsur rumah sakit Peran pimpinan, baik formil maupun non formil diperlukan dalam membentuk “nilai” dan memberi teladan.