INFECTION CONTROL RISK ASSESMENT 2015
Resiko / Akibat
Probabilitas / Frekuensi
Komponen Program
Data
Sangat besar (Frekuensi >50x /tahun)
Besar (Frekuensi 13-49x /tahun)
5
4
Substansi al Menengah (Frekuensi (Frekuensi 6-12x 3-5x /tahun) /tahun)
3
2
Kesehatan, Finansial, Hukum, Regulasi
Kehilangan Kecenderun hidup / Jarang (1-2x gan anggota kehilangan /tahun) badan / fungsi fungsi
1
5
4
Siste
Memperpanj ang masa perawatan
Klinis / Finansial sedang
Klinis / Finansial minimal
3
2
1
Kegagalan Tindakan Pencegahan
Kurangnya hand hygiene
Kurangnya edukasi terhadap staf
Kurangnya edukasi terhadap pasien
Kepatuhan dokter 72%, perawat 87,1%. HAI's terburuk (ILO 3%) menyebabkan berulangnya masa perawatan.
3
Pelatihan 11x / tahun. Kejadian pajanan 3x/tahun berakibat cedera tidak serius/minor
3
2
Edukasi rutin pada pasien baru belum berjalan baik
3
3
1
Kewaspadaan Isolasi Staf medis secara umum telah Kurangnya penggunaan APD pada menggunakan APD dengan tepat. Audit belum dilaksanakan. dilaksanakan. staf medis Didapatkan staf yang belum Kurangnya penggunaan APD pada menggunakan APD dengan tepat. Audit belum dilaksanakan. dilaksanakan. staf non medis
Kewaspadaan airborne kurang
Pasien dengan penyakit menular yang ditempatkan di ruang perawatan biasa sebanyak 30,5%
2
1
4
1
4
1
Tidak ada peratu ran
5
Peraturan ada, fasilitas tidak ada, tidak dilaksana kan
4
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Kewaspadaan droplet kurang
Pasien dengan penyakit menular yang ditempatkan di ruang perawatan biasa sebanyak 30,5%
4
1
Resiko / Akibat
Probabilitas / Frekuensi
Komponen Program
Kewaspadaan kontak kurang
Ruangan bertekanan negatif tidak ada
Data
Sangat besar (Frekuensi >50x /tahun)
Besar (Frekuensi 13-49x /tahun)
5
4
Staf medis secara umum telah menggunakan APD dengan tepat. Audit belum dilaksanakan. dilaksanakan.
Ruangan isolasi tersedia dengan standard pressure. Kebijakan merujuk pasien dengan airborne disease berat telah dilaksanakan.
Substansi al Menengah (Frekuensi (Frekuensi 6-12x 3-5x /tahun) /tahun)
3
2
Kehilangan Kecenderun hidup / gan Jarang (1-2x anggota /tahun) kehilangan badan / fungsi fungsi
1
5
2
5
Kesehatan, Finansial, Hukum, Regulasi
4
Siste
Memperpanj ang masa perawatan
Klinis / Finansial sedang
Klinis / Finansial minimal
Tidak ada peratu ran
Peraturan ada, fasilitas tidak ada, tidak dilaksana kan
3
2
1
5
4
1
5
Pencegahan Pajanan Pencegahan pajanan terhadap benda tajam dan jarum kurang
Kurangnya perlindungan respirasi pada staf medis
Kurangnya perlindungan respirasi pada staf non medis
Kejadian pajanan 3x/tahun berakibat cedera tidak serius/minor
Staf medis secara umum telah menggunakan APD respirasi dengan tepat. Audit belum dilaksanakan.
Staf non medis (misal : registrasi) belum ditentukan harus menggunakan APD. Kejadian penularan infeksi respirasi dari pasien ke petugas non medis belum pernah dilaporkan. Audit belum dilaksanakan.
5
2
1
2
1
1
5
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Resiko terpapar TB
Staf medis yang bertugas di Poli TB secara umum telah menggunakan APD respirasi dengan tepat. Audit belum dilaksanakan.
2
1
Resiko / Akibat
Probabilitas / Frekuensi
Komponen Program
Persiapan pajanan infeksi di kegawatdaruratan kurang
Data
Sangat besar (Frekuensi >50x /tahun)
Besar (Frekuensi 13-49x /tahun)
5
4
Substansi al Menengah (Frekuensi (Frekuensi 6-12x 3-5x /tahun) /tahun)
3
Staf medis secara umum telah menggunakan APD dengan tepat. Audit belum dilaksanakan. dilaksanakan.
2
Kesehatan, Finansial, Hukum, Regulasi
Kehilangan Kecenderun hidup / Jarang (1-2x gan anggota kehilangan /tahun) badan / fungsi fungsi
1
5
4
Siste
Memperpanj ang masa perawatan
Klinis / Finansial sedang
Klinis / Finansial minimal
Tidak ada peratu ran
Peraturan ada, fasilitas tidak ada, tidak dilaksana kan
3
2
1
5
4
2
1
Infeksi terkait Petugas Kesehatan Infeksi jarum infus perifer (phlebitis)
42 kasus / tahun
Infeksi jarum infus perifer (phlebitis) terkait penggunaan cairan 16 kasus / tahun konsentrat Infeksi aliran darah primer (IADP)
4
3
4
3
Tidak ditemukan
1
4
Infeksi saluran kemih (ISK)
Tidak ditemukan
Infeksi luka operasi (ILO)
7 kasus / tahun
Ventilator associated pneumonia (VAP)
0 kasus / tahun
1
5
Tidak ditemukan Tidak ditemukan
1 1
5 5
Outbreaks Sentinel Event Kesehatan Karyawan Imunisasi staf kurang
Kebijakan pemeriksaan HBsAg dan check up pada karyawan baru. Kurangnya kepatuhan akan kebijakan pemeriksaan kesehatan Karyawan mendapatkan fasilitas berobat bila sakit.
1
2
3
3
5
4 1
1
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Resiko pajanan benda tajam / jarum
Kejadian pajanan 3x/tahun berakibat cedera tidak serius/minor
2
3
Resiko / Akibat
Probabilitas / Frekuensi
Komponen Program
Data
Sangat besar (Frekuensi >50x /tahun)
Besar (Frekuensi 13-49x /tahun)
5
4
Substansi al Menengah (Frekuensi (Frekuensi 6-12x 3-5x /tahun) /tahun)
3
2
Jarang (1-2x /tahun)
1
Kesehatan, Finansial, Hukum, Regulasi
Kehilangan Kecenderun hidup / gan anggota kehilangan badan / fungsi fungsi
5
4
Siste
Memperpanj ang masa perawatan
Klinis / Finansial sedang
Klinis / Finansial minimal
Tidak ada peratu ran
Peraturan ada, fasilitas tidak ada, tidak dilaksana kan
3
2
1
5
4
Lingkungan
Kepatuhan petugas cleaning service menjalankan SOP kurang, Kebersihan lingkungan yang sesuai pemilahan limbah kurang, hasil standart kurang monitoring mikrobiologi kurang baik. Dampak terbesar terjadi ILO.
Monitoring hemodialisa kurang
Monitoring sterilisasi kurang
5
3
Semua reuse telah sesuai standart. Hasil pemeriksaan air RO hemodialisa tidak sesuai standar
2
Hasil pemeriksaan mikrobiologi baik
1
1
Koordinasi dengan Instalasi Pencegahan resiko infeksi dampak Pemeliharaan Sarana kurang baik konstruksi kurang
3
2
1
Antibiotika Rasional Kurangnya penggunaan antibiotik yang rasional
Belum ada sistem dan monitoring terhadap penggunaan antibiotika yang tidak rasional
3
2
5
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Kurangnya program monitoring penggunaan antibiotika
Telah dilakukan pemetaan kuman dari kultur pasien, tetapi hasil masih bias
2
2
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yang Berlaku Peraturan ada, fasilitas ada, tidak dilaksana kan
Peraturan ada, fasilitas ada, tidak selalu dilaksana kan
Peraturan ada, fasilitas ada, selalu dilaksana kan
3
2
1
Nilai Peta Resiko
Nilai Resiko Total
2
9
18
2
6
12
2
3
6
2
2
4
2
4
8
2
4
8
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2
4
8
yang Berlaku
Peraturan ada, fasilitas ada, tidak dilaksana kan
Peraturan ada, fasilitas ada, tidak selalu dilaksana kan
Peraturan ada, fasilitas ada, selalu dilaksana kan
3
2
1
2
Nilai Peta Resiko
Nilai Resiko Total
2
4
25
25
2
2
4
2
2
4
5
25
1
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2
2
4
yang Berlaku
Peraturan ada, fasilitas ada, tidak dilaksana kan
Peraturan ada, fasilitas ada, tidak selalu dilaksana kan
Peraturan ada, fasilitas ada, selalu dilaksana kan
3
2
1
Nilai Peta Resiko
Nilai Resiko Total
2
2
4
2
12
24
2
12
24
2
4
8
2
2
4
2
9
18
2
5
10
2 2
5 5
10 10
1
20
20
1
1
1
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2
6
12
yang Berlaku
Peraturan ada, fasilitas ada, tidak dilaksana kan
Peraturan ada, fasilitas ada, tidak selalu dilaksana kan
Peraturan ada, fasilitas ada, selalu dilaksana kan
3
2
1
Nilai Peta Resiko
Nilai Resiko Total
2
15
30
2
2
4
2
3
6
2
2
4
6
30
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3
4
12
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RENCANA TINDAK LANJUT INFECTION CONTROL AND RISK ASSESSM Komponen Program
Data
Nilai Peta Resiko
Nilai Resiko Total
Ruangan bertekanan negatif tidak ada
Ruangan isolasi tersedia dengan standard pressure. Kebijakan merujuk pasien dengan airborne disease berat telah dilaksanakan.
25
25
Imunisasi staf kurang
Kebijakan pemeriksaan HBsAg dan check up pada karyawan baru. Karyawan mendapatkan fasilitas berobat bila sakit.
20
20
Kebersihan lingkungan yang sesuai standart kurang
Kepatuhan petugas cleaning service menjalankan SOP kurang, pemilahan limbah kurang, hasil monitoring mikrobiologi kurang baik. Dampak terbesar terjadi ILO.
15
30
12
24
Infeksi jarum infus perifer (phlebitis)
42 kasus / tahun
Infeksi jarum infus perifer (phlebitis) terkait penggunaan cairan konsentrat
16 kasus / tahun
12
24
Kurangnya hand hygiene
Kepatuhan dokter 72%, perawat 87,1%. HAI's terburuk (ILO 3%) menyebabkan berulangnya masa perawatan.
9
18
Infeksi luka operasi (ILO)
7 kasus / tahun
9
18
Kurangnya edukasi terhadap staf
Pelatihan 11x / tahun. Kejadian pajanan 3x/tahun berakibat cedera tidak serius/minor
6
12
6
12
6
30
5
25
Resiko pajanan benda tajam / jarum
Kejadian pajanan 3x/tahun berakibat cedera tidak serius/minor
Kurangnya penggunaan antibiotik yang rasional Belum ada sistem dan monitoring terhadap penggunaan antibiotika yang tidak rasional Staf non medis (misal : registrasi) belum ditentukan harus menggunakan APD. Kurangnya perlindungan respirasi pada staf non Kejadian penularan infeksi respirasi dari pasien ke petugas non medis belum medis pernah dilaporkan. Audit belum dilaksanakan.
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Ventilator associated pneumonia (VAP)
0 kasus / tahun
Komponen Program
5
Data
Nilai Peta Resiko
10 Nilai Resiko Total
Outbreaks Sentinel Event
Tidak ditemukan Tidak ditemukan
5 5
10 10
Kurangnya penggunaan APD pada staf non medis
Didapatkan staf yang belum menggunakan APD dengan tepat. Audit belum dilaksanakan.
4
8
Infeksi aliran darah primer (IADP)
Tidak ditemukan
4
8
Kurangnya program monitoring penggunaan antibiotika
Telah ah dilakukan pemetaan kuman dari kultur pasien, tetapi hasil masih bias
4
12
Kewaspadaan airborne kurang
Pasien dengan penyakit menular yang ditempatkan di ruang perawatan biasa sebanyak 30,5%
4
6
Kewaspadaan droplet kurang
Pasien dengan penyakit menular yang ditempatkan di ruang perawatan biasa sebanyak 30,5%
4
6
Kurangnya edukasi terhadap pasien
Edukasi rutin pada pasien baru belum berjalan baik
3
6
Monitoring sterilisasi kurang
Hasil pemeriksaan mikrobiologi baik
3
6
Kurangnya penggunaan penggunaan APD pada staf medis
Staf medis secara secara umum telah menggunakan APD dengan tepat. Audit Audit belum dilaksanakan.
2
4
Kewaspadaan kontak kurang
Staf medis secara umum telah menggunakan APD dengan tepat. Audit belum dilaksanakan.
2
4
Pencegahan pajanan terhadap benda tajam dan jarum kurang
Kejadian pajanan 3x/tahun berakibat cedera tidak serius/minor
2
4
Kurangnya perlindungan respirasi pada staf medis
Staf medis secara umum telah menggunakan APD respirasi dengan tepat. Audit belum dilaksanakan. dilaksanakan.
2
4
Resiko terpapar TB
Staf medis yang bertugas di Poli TB secara umum telah menggunakan APD respirasi dengan tepat. Audit belum dilaksanakan.
2
4
Persiapan pajanan infeksi di kegawatdaruratan kegawatdaruratan Staf medis secara umum telah menggunakan APD dengan tepat. Audit belum kurang dilaksanakan.
2
4
Infeksi saluran kemih (ISK)
Tidak ditemukan
2
4
Monitoring hemodialisa kurang
Semua reuse telah sesuai standart. Hasil pemeriksaan air RO hemodialisa tidak sesuai standar
2
4
Pencegahan resiko infeksi dampak konstruksi kurang
Koordinasi dengan Instalasi Pemeliharaan Sarana kurang baik
2
4
Kurangnya kepatuhan akan kebijakan pemeriksaan kesehatan
Kebijakan pemeriksaan HBsAg dan check up pada karyawan baru. Karyawan mendapatkan fasilitas berobat bila sakit.
1
1
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ENT 2015 Rencana Tindak Lanjut
Kebijakan merujuk pasien dengan airborne disease berat tetap diberlakukan
Berkoordinasi dengan Panitia K3RS untuk mengadakan program imunisasi pada staf terutama yang bertugas di unit khusus seperti IGD, ICU, OK dan HD Meningkatkan kepatuhan petugas dengan sosialisasi dan pelatihan secara rutin, serta dilakukan pengumpulan data dengan audit kepatuhan SOP pembersihan lingkungan
Meningkatkan kepatuhan terhadap kebijakan penggantian infus dan SOP penggantian infus untuk mencegah angka kejadian phlebitis Berkoordinasi dengan Instalasi Farmasi dan Unit Keperawatan untuk membuat panduan penggunaan cairan konsentrat Meningkatkan kepatuhan staf medis dan non medis dalam melakukan hand hygiene dengan sosialisasi, pelatihan dan monitoring rutin 1) Meningkatkan kepatuhan staf medis dalam menjalankan program PPI 2) Pemberian edukasi pasca rawat inap terutama pada pasien post operasi 3) Program perbaikan kamar operasi agar sesuai standar 4) Meningkatkan pembersihan lingkungan agar sesuai standar yang berlaku Meningkatkan frekuensi pelatihan terhadap staf medis dan non medis, terutama terkait pencegahan infeksi terhadap pasien maupun terhadap petugas kesehatan
Meningkatkan frekuensi pelatihan terhadap staf medis dan non medis, terutama terkait pencegahan pajanan terhadap benda tajam dan jarum Membuat panduan penggunaan antibiotika rasional bekerja sama dengan Komite Medis RS Royal Progress Pembuatan SPO mengenai prosedur penanganan pasien suspek infeksi saluran pernafasan
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Monitoring penerapan SPO yang berlaku
Rencana Tindak Lanjut Resiko dapat diterima Resiko dapat diterima Monitoring penerapan SPO yang berlaku Monitoring penerapan SPO yang berlaku Monitoring penerapan SPO yang berlaku Meningkatkan ketelitian dan kepatuhan staf medis dalam melakukan kewaspadaan isolasi dalam penempatan ruangan perawatan pasien Meningkatkan ketelitian dan kepatuhan staf medis dalam melakukan kewaspadaan isolasi dalam penempatan ruangan perawatan pasien Monitoring penerapan SPO yang berlaku Monitoring penerapan SPO yang berlaku Monitoring penerapan SPO yang berlaku Monitoring penerapan SPO yang berlaku Monitoring penerapan SPO yang berlaku Monitoring penerapan SPO yang berlaku
Monitoring penerapan SPO yang berlaku
Monitoring penerapan SPO yang berlaku Monitoring penerapan SPO yang berlaku Monitoring penerapan SPO yang berlaku Monitoring penerapan SPO yang berlaku
Monitoring penerapan SPO yang berlaku
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RENCANA TINDA INFECTION CONTROL AND RI
Komponen Program
Sasaran
rate HAI s A. Menurunkan Angka Insiden Infeksi RS/incident rate
1. Surveilans Infeks
IADP
Angka insiden IADP<10 kasus per-1000 hari pemakaian kateter vena sentral (<10‰) dalam satu periode tertentu (1 bulan)yang terfokus pada pasien di ruang rawat intensif (ICU dan PICU).
Angka insiden ISK <10 kasus per-1000 hari pemakaian kateter urine menetap ISK
(<10‰) dalam satu periode tertentu (1 bulan)meliputi ruang intensif (ICU, ICCU), ruang Perawatan Neurologi (IRINA F ).
HAP
Angka insiden HAP <10 kasus per-1000 hari perawatan dengan tirah baring
(<10‰) dalam satu periode tertentu (1 bulan)meliputi ruang intensif (ICU, ICCU), ruang Perawatan Neurologi (IRINA F).
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Petugas
Sasaran audit kepatuhan melakukan kebersihan tangan adalah semua petugas baik medis dan non medis seperti dokter, perawat, petugas radiologi, petugas laboratorium, petugas fisioterapi, petugas kebersihan , dan peserta didik yang terlibat langsung dalam pelayanan pasien meliputi di unit rawat jalan, kamar operasi dan rawat inap. Sasaran pencapaian kepatuhan kebersihan tangan adalah >80% dalam jangka waktu 3 bulan
Penggunaan APD
Sasaran audit kepatuhan penggunaan APD petugas di unit perawatan khususnya di ruangan isolasi, intensif dan kamar operasi dilakukan bersamaan dengan kunjungan ruangan. Sasaran pencapaiannya adalah 100% dalam 1 bulan.
Kelengkapan PPI
Audit kelengkapan kelengkapan PPI juga dilakukan dilakukan setiap hari/setiap hari/setiap minggu/setiap minggu/setiap waktu tertentu bersamaan dengan kunjungan lapangan ke unit-unit pelayanan/perawatan untuk melihat apakah sarana dan prasarana pendukung di semua unit tersedia, tidak le ngkap atau salah/tidak digunakan. Sasaran pencapaiannya adalah >80% dalam waktu 3 bulan
3. Edukasi
Staf baru tidak dibedakan perawat, dokter atau staf lain diberikan edukasi PPI
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Peserta didik
Pelaksanaan program edukasi bagi peserta didik (dokter residen, dokter muda, mahasiswa keperawatan dan non keperawatan), diberikan saat pertama kali kegiatan orientasi dan praktek klinik di RSUP PROF.DR.R.D.KANDOU PROF.DR.R.D.KANDOU MANADO. Sasaran pencapaian adalah semua peserta didik sudah teredukasi PPI sebelum praktik klinik di RSUP PROF.DR.R.D.KANDOU MANADO (100%) dalam 1 tahun.
Pasien
Edukasi kepada pasien diberikan secara langsung dan melalui leaflet oleh IPCLN, petugas ruangan atau IPCN saat kunjungan langsung ke unit pelayanan perawatan tentang kebersihan tangan, pencegahan penyebaran penyakit infeksi di rumah sakit, dan pengelolaan penyakit infeksi di rumah sakit. Sasaran pencapaian edukasi kepada pasien adalah lebih dari 80% pasien yang sedang dirawat dapat teredukasi PPI dalam waktu 6 bulan.
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Sasaran yang dicapai adalah di CSSD dan HD meliputi peralatan single use Monitoring pelaksanaan manajemen peralatan kadaluarsa khususnya tentang yang bisa dilakukan re-use seperti pipa urogated , endotracheal tube, dialyzer , dll peralatan single use yang menjadi re-use sesuai daftar alat.
Monitoring pola pelayanan farmasi khususnya tentang dispensing obat dan dan kadaluarsa obat
Monitoring pembuangan sampah infeksius dan cairan tubuh Monitoring penanganan pembuangan darah dan komponen darah.
Sasaran yang dicapai adalah di Instalasi Farmasi khususnya di bagian Depo Farmasi RSUP PROF.DR.R.D.KANDOU MANADO meliputi petugas, alat-alat dan lingkungan sekitar Farmasi
Sasaran yang dicapai adalah di ruang-ruang perawatan dan laboratorium Sasaran yang dicapai adalah di laboratorium dan UTD PMI. meliputi petugas, darah dan komponen darah serta lingkungan di sekitarnya.
Monitoring pembuangan benda tajam dan Sasaran yang dicapai adalah di ruang perawatan, laboratorium dan incenerator
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C. Meningkatkan kualitas/kompetensi kualitas/kompetensi petugas Tim PPI Membuat usulan pelatihan lanjutan bagi tenaga IPCN
Sasaran yang dicapai adalah50% dari semua petugas IPCN (5 orang) dapat mengikuti pelatihan lanjutan dalam 1 tahun
Membuat usulan pelatihan dasar PPI bagi Sasaran yang dicapai adalah >90% dari petugas IPCLN dapat mengikuti dan tenaga IPCLN memiliki sertifikasi sertifikasi pelatihan PPI Dasar dalam 1 tahun Membuat pelatihan berkesinambungan (in (in Sasaran yang dicapai adalah >80% petugas di RSUP PROF.DR.R.D.KANDOU house training ) tentang PPI bagi seluruh MANADOdapat mengikuti kegiatan in house training dan dan kegiatan dapat petugas rumah sakit (medis dan non terlaksana minimal 1 kali dalam setahun. medis).
Mengikuti seminar/simposium/ seminar/simposium/work work shop Sasaran yang dicapai adalah 30% dari semua petugas Tim PPI (2 orang) dapat tentang PPI baik nasional maupun mengikuti seminar/simposium/ seminar/simposium/work work shop dalam 1 tahun. internasional.
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K LANJUT SK ASSESSMENT 2015
Data Indikator
Analisa
Rencana Tindak Lanjut
i Rumah Sakit
Kebijakan pemeriksaan HBsAg dan check up pada karyawan baru. Karyawan mendapatkan fasilitas berobat bila sakit.
Berkoordinasi dengan Panitia K3RS untuk mengadakan program imunisasi pada staf terutama yang bertugas di unit khusus seperti IGD, ICU, OK dan HD Meningkatkan kepatuhan petugas
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Pelatihan 11x / tahun. Kejadian pajanan 3 x/tahun berakibat cedera tidak serius/minor
Meningkatkan frekuensi pelatihan terhadap staf medis dan non medis, terutama terkait pencegahan infeksi terhadap pasien maupun terhadap petugas kesehatan
Kejadian pajanan 3x/tahun berakibat cedera tidak serius/minor
Meningkatkan frekuensi pelatihan terhadap staf medis dan non medis, terutama terkait pencegahan pajanan terhadap benda tajam dan jarum
Membuat panduan
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Tidak ditemukan
Resiko dapat diterima
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Staf medis secara umum telah menggunakan APD respirasi dengan tepat. Audit belum dilaksanakan.
Staf medis yang bertugas di Poli TB secara umum telah
Monitoring penerapan SPO yang berlaku
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No
Kegiatan
Jan
Peb
Mar
Apr
Mei
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29
Rapat Tim PPI
√
30
Peninjauan, perbaikan dan pengembangan kebijakan/SOP
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31
Usulan pelatihan lanjutan PPI
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32 33
Usulan pelatihan Dasar PPI In house training PPI
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