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DETASEMEN KESEHATAN WILAYAH 02.04.02 RUMAH SAKIT S AKIT TK. IV Dr. BRAT BR ATA ANATA Jln. Raden Mattaher N. !! Tel". 0#4$ 2!$%4 Ja&'( e-mail : [email protected]

)*RMAT LA+*RAN INSIDEN KE TK+RS RS. TK. IV Dr. BRATANATA

RAASIA; TIDA0 <=E DI>=T=2=P?; DIAP=R0AN LA+*RAN INSIDEN KN,- KT,- KTD DAN D AN KEJADIAN SENTINEL

I.

DATA PASIEN Nama : ........................ ........................... ........................... ........................... ..................... ...... ............... No MR : .......................... .................. Ran!an Ran!an : .......................... ....................... ............. "mr #

: $-% blan

& % blan ' % tahn

& % tahn ' ( tahn

& ( tahn ' %( tahn

& %( tahn ' )$ tahn

& )$ tahn ' *( tahn

& *( tahn +enis ,elamin :

a,i-la,i

Pereman

Penan!!n! biaya asien : Pribadi Pribadi Asrans Asransii S/asta S/asta +aminan 0esehatan Daerah

AS0ES AS0ES Pemerintah Pemerintah

Persahaa Persahaan# n#

+AM0ESMAS +AM0ESMAS

Tan!!al Mas, RS : 111111..........1.............1........ 111111.... ......1.............1.................+am11111111.. .........+am11111111.. II. II.

RIN2 RIN2IA IAN N 0E 0E+ADI +ADIAN AN %. Tan!!al n!!al dan dan 3a,t 3a,t Insi Insiden den Tan!!al: n!!al: 111111....... 111111.............1 ......1......... .............1.. ....1......... ............... ................ ................... .................+a ......+am...... m........ .. 111........... 4. Inside iden : ...................................................................................................................................... 1111111111111111111111111111111111111 1111111111111111111111111111111111111 ). 0ron 0ronol olo! o!is is Ins Insid iden en : ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 1111111111111111111111111111111111111 1111111111111111111111111111111111111 5. +eni +enis s Ins Insid iden en## : 0e6adian Nyaris 2edera 7 0N2 8Near miss9

0e6adian Tida, Tida, 2edera70T2 8No arm9 arm 9 0e6adian Tida, Tida, dihara,an 7 0TD 8AdBerse EBent9 7 0e6adian Sentinel 8Sentinel EBent9

(. =ran! Pertama Pertama ?an! ?an! Melaor,an Melaor,an Insiden# Insiden# 0arya/an : Do,ter 7 Pera/at 7 Pet!as lainnya Pasien 0elar!a 7 Pendamin! asien Pen!n6n! ain-lain ................................................................................................................8sebt,an9 *. Insi Inside den n ter6a ter6adi di ad ada# a# : Pasien ain-lain...................................................................................................8sebt,an9 Mis : ,arya/an 7 Pen!n6n! 7 Pendamin! 7 0elar!a asien; laor ,e 0) RS. C. Inside Insiden n menya menyan!, n!,t t asi asien en : Pasien ra/at ina Pasien ra/at 6alan Pasien "D ain-lain...................................................................................................8sebt,an9 . Temat mat Insi Inside den n o,asi ,e6adian ..................................................................................................................8sebtan9 8Temat asien berada9 F. Insiden Insiden ter6adi ter6adi ada asien asien : 8sesai 8sesai ,ass ,ass enya,it enya,it 7 sesialis sesialisasi9 asi9 Penya,it Dalam dan Sbsesialisasinya Sbsesialisasinya  Ana, dan Sbsesialisasinya Sbsesialisasinya
%$. "nit 7 Deartemen ter,ait yan! menyebab,an insiden "nit ,er6a enyebab.....................................................................................8sebt,an9 %%. %%. A,ibat Insiden Terhada Terhada Pasien# : 0ematian 2edera IrreBersibel 7 2edera
%4. Tinda,an Tinda,an yan! dila,,an se!era setelah ,e6adian; dan hasilnya : ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... %). Tinda,an Tinda,an dila,,an oleh# : Tim : terdiri dari : ................................................................................................................................. Do,ter  Pera/at Pet!as lainnya ................................................................................................................................. %5. Aa,ah ,e6adian ,e6adian yan! sama ernah ernah ter6adi di "nit 0er6a lain# lain# ?a Tida,  Aabila ya; isi ba!ian diba/ah diba/ah ini. 0aan 0aan  dan an!,ah an!,ah 7 tinda,an tinda,an aa yan! telah diambil ada "nit ,er6 a tersebt nt, mence!ah terlan!nya ,e6adian yan! sama ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... ......................................................................................................................................

Pembat aoran ParaG T!l te terima

:................................. :................................. :.................................

Penerima aoran ParaG T!l a aor

:.................................. :................................. :..................................

randin! Risi,o 0e6adian# 8Diisi oleh atasan elaor9 :
I+A"

0"NIN

MERA

N<. # J ilih sat 6a/aban.

)*RMAT LA+*RAN KE TK+RS Rmah Sa,it1111111. RAASIA; TIDA0 <=E DI>=T=2=P?; DIAP=R0AN MAIMA 4  45 +AM aoran 0ondisi Potensial 2edera 80P29 %. Tan!!al dan 3a, 3a,t t ditem, ditem,an an 0ondisi 0ondisi Potens Potensii 2edera 2edera 80P29 80P29 Tan!!al : ................ ....................... ............... ................ ................ .................+ .........+am..... am............. ................ ............... ............... ............... ............... ............... .......

4. 0P2 0P2 : ..... ........ ...... ..... ..... ...... ..... .... ..... ...... ..... ..... ...... ..... .... ..... ...... ..... ..... ...... ..... .... ..... ...... ..... ..... ...... ..... .... ..... ...... ..... ..... ...... ..... .... ..... ...... ..... ..... ...... ...... ..... .... ..... ..... ................... ........................................................................................................................................... .......................................................................................................................................... ). =ran! =ran! Pertama Pertama ?an ?an! ! Melaor, Melaor,an an Insiden Insiden## 0arya/a 0arya/an n : Do,ter Do,ter 7 Pera/at Pera/at 7 Pet!a Pet!as s lain lainny nya a Pas Pasien ien 0elar lar! !a 7 Pen Pendam amin! in! asie asien n Pen! Pen!n n6 6n n! aininlain ................ ....................... ............... ................ ................ ................ ............... ................... .................... ................ ............... ............... .................. ................. ....... 8sebt,an9 5. o,a o,asi si di,e di,eta tah hii 0P2 0P2 ..........................................................................................................................8sebt,an9 (. "nit "nit 7 Dea Dearte rtemen men ter,ai ter,aitt 0P2 0P2 ..........................................................................................................................8sebt,an9 *. Tinda,a Tinda,an n yan! yan! dila,,an dila,,an selama selama ini; dan dan hasilnya hasilnya : ........................................................................................................................................... ........................................................................................................................................... ........................................................................................................................................... C. Tinda,a Tinda,an n dila, dila,,an ,an oleh# : Tim Tim : terdiri terdiri dari dari : ......................................................................................Do,ter1111Pera/at111.... Pet!as lainnya ................................................................................................................ . Aa,ah Aa,ah ,e6adian ,e6adian yan! yan! sama ernah ernah ter6adi ter6adi di "nit "nit 0er6a lain# lain# ?a7 Tida, Aabila Aabila ya; ya; isi ba!ian diba/ah ini. 0aan  dan an!,ah 7 tinda,an aa yan! telah diambil ada "nit ,er6a tersebt nt, mence!ah terlan!nya ,e6adian yan! yan! sama .......................................................................................................................................... .......................................................................................................................................... Pembat aoran : .......................................Penerima aoran : ................................... ParaG : ................................... ParaG : ................................... Tan!!al aor : ................................... Tan!!al terima : ................................... >ormlir 4

LA+*RAN INSIDEN KESELAMATAN +ASIEN aora aoran n ini hanya hanya dibat dibat 6i,a 6i,a timbl timbl ,e6adi ,e6adian an yan! yan! menya menyan!, n!,t t asien asien.. aora aoran n bersiGat anonim; tida, mencantm,an nama; hanya dierl,an rincian ,e6adian; analisa enyebab dan re,omendasi. "nt, men!isi laoran ini sebai,nya dibaca Pedoman Pelaoran Insiden 0eselamatan Pasien 8I0P9; bila ada ,erancan ersesi; isilah sesai den!an emahaman yan! ada.

Isilah sema data ada aoran Insiden 0eselamatan Pasien den!an len!,a. +an!an di,oson!,an a!ar data daat dianalisa. Se!era Se!era ,irim, ,irim,an an laora laoran n ini lan!s lan!sn! n! ,e 0omite 0omite Nasion Nasional al 0esela 0eselamat matan an Pasien Pasien 80N0P9. 0=DE R"MA SA0IT : ................................... I.

DATA R"MA SA SA0IT: IT: 0eemili,an Rmah Sa,it : Pemerintah P K emerintah Pemerintah KPemerintah Daerah 8ProBinsi 7 0ab 7 0ota9 K TNI 7P=RI  PriBat K PriBat <"MN < K "MN 7 <"MD +enis Rmah Sa,it : RS R K S "mm RS R K S 0hss: K RS Ib dan Ana, KRS RS Par KRS RS Mata RS R K S =rthoedi R K S +antn! R K S +i/a R K S 0staR K S 0hss lainnya ............................................................................................................................... ............. 0elas Rmah Sa,it "mm 0elas Rmah Sa,it 0hss A A < < 2 2 D 0aasitas temat tidr : .................................................................................temat tidr  Proinsi 8lo,asi RS9:........................................................................................................... Tan!!al aoran1111111111111111111111111111111 Insiden di ,irim ,e 0N0P : ................................................................................................. II. II. DAT DATA PASIEN IEN "mr # : $-% $ K -% blan & K % blan ' % tahn  & K & % tahn ' ( tahn  &  K & ( tahn ' %( tahn K &  & %( tahn ' )$ tahn K &  & )$ tahn ' *( tahn K &  & *( tahn +enis ,elamin : a,i-la,i  K a,i-la,i Pereman KPereman Penan!!n! biaya asien :   KPribadi; Pribadi;  Asransi K S/asta;  AS0ES K Pemerintah; Persahaan# P K ersahaan# K+AM0ESMAS +AM0ESMAS K+aminan +aminan 0esehatan Daerah Tan!!al Mas, RS : ........................ ......................................+am..... ............... .......................+am.............................. ......................... ...... III. III. RIN2 RIN2IA IAN N 0E+A 0E+ADI DIAN AN %. Tan!!al n!!al dan dan 3a,t 3a,t Insi Insiden den Tan!!al n!!al :.............. :...................... ................ ............... ............... .................. .............+am ...+am........ ................ ................ ............... ................ .................. ............. .... 4. Inside Insiden n :...... :.......... ........ ........ ........ ........ ........ ........ ....... ....... ....... ....... ........ ....... ....... ....... ....... ........ ....... ....... ....... ....... ........ ....... ......... ......... ....... ....... ....... ........ ...... .. ). 0ron 0ronol olo! o!is is Insi Inside den n ...................................................................................................................................... ...................................................................................................................................... ...................................................................................................................................... 5. +eni +enis s Ins Insid iden en## : K 0e6adi 0e6adian an Nyaris Nyaris 2eder 2edera a 7 0N2 8Near 8Near miss9 miss9  K 0e6adian Tida, Tida, 2edera70T 2edera70T2 2 8No arm Incident9 Incident9 K 0e6adi 0e6adian an Tida, Tida, dihara dihara,a ,an n 7 0TD 8AdBer 8AdBerse se EBent9 7  0e6adian  K 0e6adian Sentinel 8Sentinel EBent9 (. =ran! Pertama Pertama ?an! an! Melao Melaor,an r,an Insiden# Insiden# 0arya/an 0arya/an : Do,ter Do,ter 7 Pera/at Pera/at 7 Pet!as Pet!as lainnya Pasien P K asien K0elar!a 7 Pendamin! asien Pen P K en!n6 n6n! n! ainKainlain................................................................................................................8sebt,an9 *. Insi Inside den n ter6 ter6ad adii ada ada## : K Pasien K ain-lain .....................................................................................................................8sebt,an9 Mis : ,arya/an 7 Pen!n6n! 7 Pendamin! 7 0elar!a asien; laor ,e 0) RS. C. Inside Insiden n menya menyan!, n!,t t asi asien en :   K Pasien  Pasien ra/at ina K Pasien  Pasien ra/at 6alan K Pasien  Pasien "D   Kain-lain ain-lain ....................................................................................................8sebt,an9 . Temat Insiden Insiden o,asi o,asi ,e6adian ,e6adian ..............................................................................8sebt,an9 8Temat asien berada9

F. Insiden Insiden ter6adi ter6adi ada asien asien : 8sesa 8sesaii ,ass ,ass enya enya,it ,it 7 sesi sesialisa alisasi9 si9  Penya,it  K Penya,it Dalam dan Sbs Sbsesi esiali alisas sasiny inya a K Ana, Ana, dan dan Sbs Sbse esi sial alis isas asiny inya a K a,tor ,ontribt ,ontribtor or 8bisa ilih lebih lebih dari %9 a. >a,tor >a,tor E,sternal E,sternal 7 di lar  RS b. >a,tor =r!anisasi =r!anisasi dan Mana6emen c. >a,tor in!,n!an ,er6a d. >a,tor Tim e. >a,tor Pet!as H 0iner6a G. >a,tor T!as T!as !. >a,tor Pasien h. >a,tor 0omni,asi %. Penyebab Penyebab lan!s lan!sn! n! 8Direct 8Direct 7 Proimate Proimate77 Immediate Immediate 2ase9 2ase9 .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... 4. A,ar enyebab enyebab masalah masalah 8nderlyin! 8nderlyin! root case9 case9 .................................................................................................................................... .................................................................................................................................... .................................................................................................................................... ................................................................................................................................... ). Re,o Re,ome mend ndas asii 7 Sol Solsi si N= A0AR MASAA RE0=MENDASI7S="SI

N<. # J ilih sat 6a/aban; ,ecali bila berendaat lain.