FORMAT FORMAT LAPORAN INSIDEN KE Tim Keselamatan Pasien Puskesmas Puskesmas : ............................. ................................ ... (RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAKSIMAL 2x24 JAM) LAPORAN INSIDEN KNC, KTC, KTD, DAN KEJADIAN SENTINEL I.
DAT DATA PASIEN ASIEN Nama : ..................................................................................................... ............................ No MR : ...... ........ ..... ...... ...... ...... ..... ..... ...... ...... ...... ..... ..... ...... ...... ..... Ruangan : ...................................................... Umur * ()" bulan "bulan + " %a,un : " %a,un + - %a,un - %a,un + "- %a,un "- %a,un + '( %a,un '( %a,un + - %a,un - %a,un
/aki)laki
Perempuan
Jenis kelamin
: Penanggung biaya pasien : Umum 1PJS !ese,a%an 1PJS P1I
Asuransi S0as%a Perusa,aan Jaminan !ese,a%an Daera, Tanggal Tanggal Masuk RS : ..................... ................................ .............. ... Jam : ..................... ................................ .................... ......... II.
RINIA RINIAN N !EJADI !EJADIAN AN ". Tanggal #an $ak%u $ak%u Insi#en Tanggal Tanggal : ..................... ................................ ..................... ................ ...... Jam : .................. ............................. ..................... ............ .. &. Insi#en: ..................... ................................ ..................... ..................... ..................... ..................... ..................... ..................... ..................... ............ ........................... ....................................................................................................................... .............................. '. !ronologis !ronologis Insi#en Insi#en : ....................................................................................................................... .............................. ....................................................................................................................... .............................. ....................................................................................................................... ..............................
2. Jenis Insi#en* : !e5a#ian Nyaris e#era 6 !N Near miss; !e5a#ian Ti#ak e#era 6 !T No ,arm; !e5a#ian Ti#ak Di,arapkan 6 !TD A#=erse E=en%; 6 !e5a#ian Sen%inel sen%inel e=en%;
-. 3rang Per%ama 4ang Melaporkan Insi#en* !arya0an : Dok%er 6 Pera0a% 6 Pe%ugas lainnya Pasien !eluarga 6 Pen#amping Pasien Pengun5ung /ain) lain .............................................................................................................. sebu%kan;
. Insi#en %er5a#i pa#a * : Pasien /ain) lain .............................................................................................................. sebu%kan; Misalnya : !arya0an 6 Pengun5ung 6 Pen#amping 6 !eluarga pasien7 lapor ke !' Puskesmas 8. Insi#en menyangku% pasien : Pasien ra0a% inap Pasien ra0a% 5alan Pasien U>D /ain) lain .............................................................................................................. sebu%kan;
9. Tempa% Insi#en /okasi !e5a#ian ..................................................................................................... sebu%kan; Tempa% pasien bera#a; <. Insi#en %er5a#i pa#a pasien : sesuai kasus penyaki%;
Penyaki% Dalam Anak 1e#a, 3bs%e%ri >inekologi T?T Ma%a Sara@ Anas%esi !uli% #an !elamin Jan%ung Paru Ji0a
/okasi !e5a#ian ................................................................................................... sebu%kan; "(.Uni% 6 Depar%emen yang %erkai% yang menyebabkan insi#en Uni% ker5a penyebab ............................................................................................ sebu%kan; "".Akiba% Insi#en Ter,a#ap Pasien *: !ema%ian e#era Invers!"e 6 e#era 1era% e#era Revers!"e 6 e#era se#ang e#era Ringan Ti#ak a#a e#era
"&.Tin#akan yang #ilakukan segera se%ela, ke5a#ian7 #an ,asilnya : ....................................................................................................... ....................................................................................................................... .............................................................................. ....................................................................................................................... ...............................
"'.Tin#akan #ilakukan ole,* : Tim : %er#iri #ari : ............................................................................................................ ...... Dok%er Pera0a% Pe%ugas lainnya ......................................................................................................... ............ Apaka, ke5a#ian yang sama perna, %er5a#i #i Uni% !er5a lainB* 4a
Ti#ak
Apabila 4a7 isi bagian #iba0a, ini. !apanB Dan /angka,6%i#akan apa yang #iambil pa#a Uni% ker5a %ersebu% un%uk menega, %erulangnya ke5a#ian yang samaB ....................................................................................................................... ............................. ....................................................................................................................... ............................. ....................................................................................................................... ............................. Pembua% /aporan Para@ Tgl Terima
Penerima /aporan Para@ Tgl /apor
>ra#ing Resiko !e5a#ian* #apa% #iisi a%asan pelapor; BIR
!IJA
N1. *C pili, sa%u 5a0aban
KNIN"
MERA!
"2. "2. "2.
FORMAT LAPORAN INSIDEN KE Tim Keselamatan Pasien Puskesmas Puskesmas : ..................................... (RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAKSIMAL 2x24 JAM) La#$%an K$n&isi P$tensial Ce&e%a 'KPC( ". Tanggal #an $ak%u #i%emukan !on#isi Po%ensial e#era !P; Tanggal : ................................................ Jam : ......................................... &. !P : .......................................................................................................... ........................... ....................................................................................................................... .............................. ....................................................................................................................... .............................. '. 3rang Per%ama 4ang Melaporkan Insi#en* !arya0an : Dok%er 6 Pera0a% 6 Pe%ugas lainnya Pasien !eluarga 6 Pen#amping Pasien Pengun5ung /ain) lain .............................................................................................................. sebu%kan;
2.
/okasi #ike%emukan !P ....................................................................................................................... ..... sebu%kan; -. Uni%6Depar%emen %erkai% !P ....................................................................................................................... ..... sebu%kan; . Tin#akan yang #ilakukan selama ini7 #an ?asilnya : ....................................................................................................................... .............................. ....................................................................................................................... .............................. 8. Tin#akan #ilakukan ole,* : Tim : %er#iri #ari : ............................................................................................................ ...... Dok%er Pera0a% Pe%ugas lainnya ......................................................................................................... ............ Apaka, ke5a#ian yang sama perna, %er5a#i #i Uni% !er5a lainB* 4a
Ti#ak
Apabila 4a7 isi bagian #iba0a, ini.
9. 9. 9.
!apanB Dan /angka,6%i#akan apa yang #iambil pa#a Uni% ker5a %ersebu% un%uk menega, %erulangnya ke5a#ian yang samaB ....................................................................................................................... ............................. ....................................................................................................................... ............................. ....................................................................................................................... ............................. Pembua% /aporan Para@ Tgl Terima
Penerima /aporan Para@ Tgl /apor
