Formulir Laporan Insiden Keselamatan Pasien RS (eksternal).rtf

KOMITE KESELAMATAN PASIEN RUMAH SAKIT (KKPRS-PERSI) TIM KESELAMAT KE SELAMATAN AN PASIEN RUMAH SAKIT HAJI HAJ I JAKARTA Jalan Raya Pondok Gede No. 4, Jaka!a T"#$ %&' No. Tel*. Tel*. +%-, a. +%- RAHASIA

ORMULIR LAPORAN INSIEN KESELAMATAN PASIEN RUMAH SAKIT KODE RUMAH SAKIT : .......................

(Lewat : http://www.inapat-safety.o.i! /pos/"#i$

I.

ATA RUMAH SAKIT /

Ke*e#"l"kan R$#a0 Sak"! / 

%e&eintah %#sat



%e&eintah Daeah (%opinsi / Ka'. / Kota$



TI / %OLRI



Swasta



)UM / )UMD

Jen"1 RS / 

RS U&#&



RS Kh#s#s



RSIA



RS %a#



RS Mata



RS Othope!i



RS *ant#n+



RS *iwa



RS K#sta



RS Kh#s#s ,ainnya ............................................ ................................................................... .............................................. .........................

Kela1 RS 

A



)

KOMITE KESELAMATAN PASIEN RUMAH SAKIT (KKPRS-PERSI) TIM KESELAMAT KE SELAMATAN AN PASIEN RUMAH SAKIT HAJI HAJ I JAKARTA Jalan Raya Pondok Gede No. 4, Jaka!a T"#$ %&' No. Tel*. Tel*. +%-, a. +%-







D

Kapasitas Kapasitas Te&pat Te&pat Ti!# Ti!#

: .......... ............... .......... .......... ..... Te&pat Ti!# Ti!#

%op %opin insi si (Lo"a (Lo"asi si RS$

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

Tan++a, Lapoan Insi!en !i"ii& "e KK%RS-%esi : ................................................ ................................................

II. ATA PASIEN /   0 tah#n

U#$ 2

1 0 '#,an  0 tah#n

1 0 tah#n  2 tah#n

1 2 tah#n  02 tah#n

1 02 tah#n  3 tah#n

1 3 tah#n  42 tah#n

1 42 tah#n Jen"1 Kela#"n

/ La"i-,a"i

%ee&p#an

Penan33$n3 "aya *a1"en /

%i'a!i

As#ansi Swasta

ASKES %e&eintah %e#sahaan 5 Tan33al Ma1$k RS

*AMKESMAS / ............................................ Ja# ..................................

III. RIN5IAN KEJAIAN 0.

Tan33al dan 6ak!$ In1"den

Tan++a, an++a,

: ...... ......... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ..... *a& ...... ......... ...... ...... ...... ...... ...... ...... ...... ...... ...

6.

In1"den

.................................................................. .............................................. .................................. ........... / ...........................................

3.

Konolo3"1 In1"den

............................................ ................................................................... .............................................. .............................................. .............................................. ......................... .. ............................................ ................................................................... .............................................. .............................................. .............................................. ......................... .. ............................................ ................................................................... .............................................. .............................................. .............................................. ......................... .. ............................................ ................................................................... .............................................. .............................................. .............................................. ......................... .. ............................................ ................................................................... .................................. ...........


7.

Jen"1 In1"den2 /

Ke8a!ian yais e!ea / K ( Near miss) Ke8a!ian Ti!a" Ti!a" Dihaap"an Dihaap"an / KTD (Adverse Event) Event) / Ke8a!ian Sentine, (Sentinel Event) 2.

Oan3 Pe!a#a 7an3 Mela*okan In1"den2

Kayawan : Do"te / %eawat / %et#+as ,ainnya %asien Ke,#a+a / %en!a&pin+ %asien %en+#n8#n+ Lain-,ain ........................................... .................................................................. .............................................. .........................(se'#t"an$ ..(se'#t"an$ 4.

In1"den !e8ad" *ada2 /

%asien Lain-,ain ........................................... .................................................................. .............................................. .........................(se'#t"an$ ..(se'#t"an$ Mis. : Kayawan / %en+#n8#n+ / %en!a&pin+ / Ke,#a+a %asien9 ,apo "e K3 RS .

In1"den #enyan3k$! *a1"en /

%asien awat inap %asien awat 8a,an %asien U;D Lain-,ain ........................................... .................................................................. .............................................. .........................(se'#t"an$ ..(se'#t"an$ <.

Te#*a! In1"den I n1"den

Lo"asi "e8a!ian............................................. "e8a!ian.................................................................... .......................................(se'#t"an$ ................(se'#t"an$ (te&pat pasien 'ea!a$ =.

In1"den !e8ad" *ada *a1"en / (1e1$a" ka1$1 *enyak"! 9 1*e1"al"1a1")

%enya"it Da,a& !an s#'spesia,isasinya Ana" !an s#'spesia,isasinya )e!ah !an s#'spesia,isasinya O'steti ;ine"o,o+i !an s#'spesia,isasinya THT !an s#'spesia,isasinya Mata !an s#'spesia,isasinya


Saaf !an s#'spesia,isasinya Anastesi !an s#'spesia,isasinya K#,it>Ke,a&in !an s#'spesia,isasinya *ant#n+ !an s#'spesia,isasinya %a# !an s#'spesia,isasinya *iwa !an s#'spesia,isasinya Lain-,ain ........................................... .................................................................. .............................................. .........................(se'#t"an$ ..(se'#t"an$ 0.

Un"! 9 de*a!e#en !eka"! yan3 #enyeakan "n1"den

Unit "e8a penye'a' ............................................ ................................................................... ................................(se'#t"an$ .........(se'#t"an$ 00.

Ak"a! In1"den Te0ada* Pa1"en2 /

Ke&atian e!ea ie?esi',e / @e!ea 'eat e!ea Re?esi'e, / e!ea se!an+ e!ea in+an Ti!a" a!a @e!ea 06.

T"ndakan 7an3 "lak$kan 1e3ea 1e!ela0 ke8ad"an, dan 0a1"lnya /

............................................ ................................................................... .............................................. .............................................. .............................................. ......................... .. ............................................ ................................................................... .............................................. .............................................. ......................... 03.

T"ndakan d"lak$kan ole02 /

Ti& : te!ii !ai : ............................................ ................................................................... .............................................. ........................... .... Do"te %eawat %et#a+s ,ainnya ............................................ ................................................................... .............................................. .............................. ....... 07. a

A*aka0 ke8ad"an yan3 1a#a *ena0 !e8ad" d" Un"! Ke8a la"n:2

Ti!a"

Apa'i,a ya9 isi 'a+ian !i'awah ini. KapanB Dan ,an+"ah / tin!a"an apa yan+ te,ah !ia&'i, pa!a Unit Ke8a tese'#t #nt#" &en@e+ah te#,an+nya "e8a!ia yan+ sa&aB


............................................ ................................................................... .............................................. .............................................. .............................................. ......................... .. ............................................ ................................................................... .............................................. .............................................. .............................................. ......................... .. ............................................ ................................................................... .............................................. .............................................. .............................................. ......................... .. ............................................ ................................................................... .............................................. .......................

IC. IC. TIPE INSIEN Insi Insi!e !en n

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

Tipe Tipe Insi!e Insi!en n

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

S#'tipe S#'tipe Insi!en Insi!en

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

C. ANALISA PEN7E;A; INSIEN ala ala# #

*en3 *en3"1 "1"a "an n *eny *enye ea a lan3 lan31$ 1$n3 n3 a!a$ a!a$ aka aka *eny *enye ea a #a1a #a1ala la0 0 da*a da*a!!

#en33$nakan ak!o kon!"$!o ('isa pi,ih ,e'ih !ai 0$

a.

a"to E"stena, / !i ,#a RS

'.

a"to O+anisasi !an Mana8e&en

@.

a"to Lin+"#n+an Ke8a

!.

a"to Ti&

e.

a"to %et#+as / Staf

f.

a"to T#+as

+.

a"to %asien

h.

a"to Ko&#ni"asi

0.

%enye'a' ,an+s#n+ (Direct / Proximate / Immediate Cause)

   . 6.

A"a penye'a' &asa,ah (Underlying root cause)


   

3. No.

Re"o&en!asi / So,#si Aka Ma1ala0

Reko#enda1" 9 Sol$1"

).5

: pi,ih sat# 8awa'an9 "e@#a,i 'i,a 'epen!apat ,ain.

Saan

: 'a@a 'a@a %e!o&an %e!o&an %e,apo %e,apoan an Insi!en Insi!en Kese,a& Kese,a&atan atan %asien (IK%$

Formulir Laporan Insiden Keselamatan Pasien RS (eksternal).rtf

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