Laporan Insiden Eksternal (New) PATIENT SAFETY

RAHASIA

LAPORAN INSIDEN KESELAMA KESELAM ATAN TAN PASIEN KKP-RS KODE RS : .................. (lewat : http://www.inapat-safety http://www.inapat-safety.or. .or.id id / pos / kurir) 1.

2.

DATA RUMAH SAKIT a.

Kepemilikan Rumah Sakit :  emerintah usat  emerintah !aerah (ro"insi / Ka# / Kota)  $%I /&'RI  Swasta  *% / *!

#.

+enis RS :  RS mum  RS Khusus :  RSIA  RS aru  RS *ata  RS &rthopedi  RS+antun,  RS +iwa  RS Kusta  RS Khusus lainnya ..........................................................................

.

Kelas RS  A   !

d.

Kapas Kapasita itas s tempa tempatt tidur tidur : ....... ........... ........ ........ ....... ....... ....... ....... ........ ....... ....... ....... ....... ........ ....... ....... ....... ....... ........ ........ ........ ....

e.

ropin ropinsi si (lok (lokasi asi RS) : ....... ........... ........ ........ ....... ....... ....... ....... ........ ....... ....... ....... ....... ........ ....... ....... ....... ....... ........ ....... ....... ....... ..... ..

f.

$an,,a n,,all 'apor 'aporan an Insi Inside den n di kirim kirim ke KKKK-RS RS : ...... ......... ..... ..... ...... ..... .... ..... ...... ..... ..... ...... ..... .... ..... ...... ...

DATA PASIEN a.

Umur *

b.

Jeni !e"amin

 1 0 #ulan 2 0 tahun :  -0 #ulan  1 0 tahun 2 3 tahun  1 3 tahun 2 03 tahun  1 03 tahun 2 4 tahun  1 4 tahun 2 53 tahun  1 53 tahun

:  'aki-laki

 erempuan

RAHASIA

(.

#.

Penan$$un$ bia%a &aien :  ri#adi  Asuransi Swasta  ASK6S emerintah  erusahaan7  +A*K6S*AS  +A*K6S!A

'.

Tan$$a" Mau! RS : .................................................. +am ...........................

RIN)IAN KEJADIAN a.

Tan$$a" 'an a!+u Ini'en $an,,al : ....................................................................... +am ..........................

b.

Ini'en :  ..........................................................................................................

#.

Kr,n,",$i Ini'en .......................................................................................................................... ..........................................................................................................................

'.

Jeni Ini'en* :  Ke8adian %yaris edera / K% (Near miss)  Ke8adian $idak edera / K$ (No Harm)  Ke8adian $idak diharapkan / K$! (Adverse Event) / Ke8adian Sentinel (Sentinel Event)

e.

Oran$ Per+ama an$ Me"a&,r!an Ini'en*  Karyawan : !okter / erawat / etu,as lainnya  asien  Keluar,a / endampin, pasien  en,un8un,   'ain-lain ..................................................................................ebu+!an/

0.

Ini'en +era'i &a'a* :  asien   'ain-lain ..................................................................................ebu+!an/ *is : karyawan/ en,un8un,/ endampin,/ Keluar,a pasien9 lapor ke K4RS.

$.

Ini'en men%an$!u+ &aien :  asien rawat inap  asien rawat 8alan  asien !  'ain-lain .............................. ....................................................ebu+!an/

.

Tem&a+ Ini'en 'okasi ke8adian ............................................................................ebu+!an/

RAHASIA

6.

i.

Ini'en +era'i &a'a &aien : euai !au &en%a!i+ 3 &eia"iai/  enyakit !alam dan Su#spesialisasinya  Anak dan Su#spesialisasinya  edah dan Su#spesialisasinya  &#stetri ynekolo,i dan Su#spesialisasinya  $H$ dan Su#spesialisasinya  *ata dan Su#spesialisasinya  Saraf dan Su#spesialisasinya  Anastesi dan Su#spesialisasinya  Kulit ; Kelamin dan Su#spesialisasinya  +antun, dan Su#spesialisasinya  aru dan Su#spesialisasinya  +iwa dan Su#spesialisasinya   'ain-lain ....................................................................................ebu+!an/

 .

Uni+ 3 De&ar+emen +er!ai+ %an$ men%ebab!an ini'en nit ker8a penye#a# ...................................................................... ebu+!an/

!.

A!iba+ Ini'en Tera'a& Paien* :  Kematian  edera Irre"ersi#el / edera erat  edera Re"ersi#el / edera Sedan,  edera Rin,an  $idak ada edera

".

Tin'a!an %an$ 'i"a!u!an e$era e+e"a !ea'ian4 'an ai"n%a : .......................................................................................................................... ..........................................................................................................................

m.

Tin'a!an 'i"a!u!an ,"e* :  $im : terdiri dari : ..........................................................................................  !okter   erawat  etu,as lainnya ............................................................................................

n.

A&a!a !ea'ian %an$ ama &erna +era'i 'i Uni+ Kera "ain5*  
TIPE INSIDEN

RAHASIA

a.  #. . 7.

Insiden $ipe Insiden Su#tipe Insiden

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

ANALISA PENE8A8 INSIDEN Da"am &en$iian &en%ebab "an$un$ a+au a!ar &en%ebab maa"a 'a&a+ men$$una!an 9a!+,r !,n+ribu+,r (#isa pilih le#ih dari 0) 0) >aktor 6ksternal / di luar RS ?) >aktor &r,anisasi dan *ana8emen 4) >aktor 'in,kun,an ker8a @) >aktor $im 3) >aktor etu,as / Staf   5) >aktor $u,as ) >aktor asien B) >aktor Komunikasi a.        

enye#a# lan,sun, (Direct / Proximate/ Immediate Cause) ......................................................................................................................... ......................................................................................................................... ......................................................................................................................... .........................................................................................................................

       

Akar penye#a# masalah (underlying  root cause) .......................................................................................................................... .......................................................................................................................... .......................................................................................................................... ..........................................................................................................................

#.

. %o.

Rekomendasi / Solusi Akar *asalah

Rekomendasi/Solusi

N8. * : &i"i a+u aaban4 !e#ua"i bi"a ber&en'a&a+ "ain. Saran : ba#a Pe',man Pe"a&,ran Ini'en Kee"ama+an Paien IKP/