1. mengenal kesalahan atau kemungkinan kesalahan selama mendapat asuhanmengenal kesalahan atau kemungkinan kesalahan selama mendapat asuhan klinis,
klinis, 2.
2. mengenal faktmengenal faktor-faktor yang or-faktor yang berpengaruh terberpengaruh terhadap terjadi keshadap terjadi kesalahan/risalahan/risiko,iko, 3.
3. belajar dari belajar dari pengalaman terhadap pengalaman terhadap setiap adanya setiap adanya adverse event,adverse event, 4.
4. memastikan bahwa memastikan bahwa dilakukan tindakan dilakukan tindakan untuk mencegah untuk mencegah terjadi kesalahan/risiko,terjadi kesalahan/risiko, dan
dan 5.
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BAB IV BAB IV
PELAPORAN INSIDEN PELAPORAN INSIDEN
Banyak metode yang Digunakan untuk mengidentifikasi risiko, salah satu Banyak metode yang Digunakan untuk mengidentifikasi risiko, salah satu caranyaadalah dengan mengembangkan sistem pelaporan insiden Keselamatan Pasien caranyaadalah dengan mengembangkan sistem pelaporan insiden Keselamatan Pasien (IKP)dan sistem analisis. Dapat dipastikan bahwa sistem pelaporan akan mengajak (IKP)dan sistem analisis. Dapat dipastikan bahwa sistem pelaporan akan mengajak semuaorang dalam organisasi untuk peduli akan bahaya / potensi bahaya yang semuaorang dalam organisasi untuk peduli akan bahaya / potensi bahaya yang dapatterjadi kepada pasien. Pelaporan iuga penting digunakan untuk memonitor dapatterjadi kepada pasien. Pelaporan iuga penting digunakan untuk memonitor upayapencegahan terjadinya error sehingga diharapkan dapat mendorong upayapencegahan terjadinya error sehingga diharapkan dapat mendorong dilakukannyainvestigasi lebih lanjut.pelaporan insiden penting karena pelaporan akan dilakukannyainvestigasi lebih lanjut.pelaporan insiden penting karena pelaporan akan menjadi awal proses pembelajaran untuk mencegahkejadian yang sama terulang menjadi awal proses pembelajaran untuk mencegahkejadian yang sama terulang kembali.Insiden yang dilaporkan adalah kejadian yang sudah teriadi, poiensial teriadi kembali.Insiden yang dilaporkan adalah kejadian yang sudah teriadi, poiensial teriadi ataupun yang nyaris terjadi.
ataupun yang nyaris terjadi. Alur pelapora
Alur pelaporan insiden kn insiden ke Tim Keselae Tim Keselamatan Pasien matan Pasien Puskesmas (KPPuskesmas (KPP)Medono :P)Medono : 1.
1. Apabila terjadi suatu Apabila terjadi suatu insiden (KNC/ insiden (KNC/ KTD) KTD) wajib segerawajib segera
2. ditindaklaniuti (dicegah / ditangani) oleh Petugas Unit (Tim PMKP) untuk 2. ditindaklaniuti (dicegah / ditangani) oleh Petugas Unit (Tim PMKP) untuk mengurangi dampak / akibatyang tidak diharapkan dan melaporkan insiden Ke mengurangi dampak / akibatyang tidak diharapkan dan melaporkan insiden Ke Tim KPP.
Tim KPP. 3. Se
3. Setelah telah ditindakladitindaklanjuti, njuti, Ketua Ketua Tim Tim KPP KPP segera segera membuat laporan membuat laporan insidennyainsidennya dengan mengisi
dengan mengisi 4.
4. formulir Laporan formulir Laporan insiden insiden (Paling (Paling lambat lambat 2x24 2x24 iam iam ).). 5.
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7. Ketua Tim KPP akan menganalisis kembali hasil Investigasi dan Laporaninsiden 7. Ketua Tim KPP akan menganalisis kembali hasil Investigasi dan Laporaninsiden
untuk menentukan apakah perlu
untuk menentukan apakah perlu ”” dilakukan investigasi lanjutan RCA)dengan dilakukan investigasi lanjutan RCA)dengan melakukan Regrading
melakukan Regrading
8. Ketua Tim KPP melaporkan hasil Investigasi dan Laporan insiden ke kepala 8. Ketua Tim KPP melaporkan hasil Investigasi dan Laporan insiden ke kepala puskesmas
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BAB V BAB V PENUTUP PENUTUP
Demikian pedoman manajemen resiko Puskesmas Medono dibuat sebagai acuan Demikian pedoman manajemen resiko Puskesmas Medono dibuat sebagai acuan dalam penerapan
dalam penerapan manajememanajemen n resiko resiko di di Puskesmas Medono Puskesmas Medono agar agar penyelenggaraanpenyelenggaraan pelayanan lebih aman dan terhindar dari bahaya dan kesalahan yang merugikan baik pelayanan lebih aman dan terhindar dari bahaya dan kesalahan yang merugikan baik untuk pemberi pelayanan, pengguna pelayanan maupun lingkungan Puskesmas untuk pemberi pelayanan, pengguna pelayanan maupun lingkungan Puskesmas Medono.
Medono.
Penerapan manajemen
Penerapan manajemen resikoharuresikoharus s didukung dengan didukung dengan komitmen dan komitmen dan peran peran aktif dariaktif dari Kepala Puskesmas, Penanggung Jawab Upaya, Penanggung Jawab Pelayanan, dan Kepala Puskesmas, Penanggung Jawab Upaya, Penanggung Jawab Pelayanan, dan Pelaksana kegiatan sehingga diharapkan dapat meningkatkan kualitas Pelaksana kegiatan sehingga diharapkan dapat meningkatkan kualitas penyelenggaraan pelayanan Puskesmas Medono.
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Lampiran 1 (Dibuat land scape) Lampiran 1 (Dibuat land scape) FORMULIR RCA
FORMULIR RCA
PEMERINTAH KOTA PEKALONGAN PEMERINTAH KOTA PEKALONGAN
DINAS KESEHATAN DINAS KESEHATAN
PUSKESMAS MEDONO
PUSKESMAS MEDONO
Jl.Setia Bakti Pekalongan Telp (0285) 4420399 Jl.Setia Bakti Pekalongan Telp (0285) 4420399
e-mail:
e-mail: puskesmasmepuskesmasmedono@doctordono@doctor.com.com
ROOT CAUSE ANALYSIS ROOT CAUSE ANALYSIS
( RCA ) ( RCA ) D.
D. AnalisisterAnalisisterhadap hadap KTD/KTC/KNC KTD/KTC/KNC :: Kasus Kasus ... ... ... ... E. E. Tim Tim RCA RCA :: Ketua Ketua : : ...
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I.
I. Faktor-faktoFaktor-faktor r yang yang terkaitdengankterkaitdengankejadian:ejadian: a.
a. Faktor-faktFaktor-faktor or yang yang terkaitlangsuterkaitlangsung:ng: 1)
1) 2) 2) b.
b. Faktor-faktFaktor-faktor or yang yang menunjangterjmenunjangterjadinyakejadianadinyakejadian:: 1)
1) 2) 2) J.
J. AnalisisakarmAnalisisakarmasalah asalah (gambarkan (gambarkan diagram diagram tulangikan/potulangikan/pohonmasalah)honmasalah) 1)
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Cancel Anytime. Lampiran 2 Lampiran 2 Formulir FMEA Formulir FMEA Tahapan Tahapan Proses Proses Failure Failure Mode
Mode Akibat Akibat SS
Kemungkinan Kemungkinan Sebab Sebab OO Upaya Upaya Kendali Kendali yang yang Sudah Sudah Dilakukan Dilakukan D RPN
D RPN Kegiatan Kegiatan yangyang direkomendasikan direkomendasikan Penanggung Penanggung Jawab Jawab Kegiatan Kegiatan yg yg Dilakukan Dilakukan S O D RPN S O D RPN PEMERINTAH KOTA PEKALONGAN
PEMERINTAH KOTA PEKALONGAN DINAS KESEHATAN
DINAS KESEHATAN