POLRI DAERAH JAWA TIMUR
POLRI DAERAH JAWA TIMUR
BIDANG KEDOKTERAN DAN KESEHATAN
BIDANG KEDOKTERAN DAN KESEHATAN
RUMAH SAKIT BHAYANGKARA TINGKAT III LUMAJANG
RUMAH SAKIT BHAYANGKARA TINGKAT III LUMAJANG
JL. KYAI ILYAS NO. 07 LUMAJANG
JL. KYAI ILYAS NO. 07 LUMAJANG
BAB I BAB I DEFINISI DEFINISI
1.
1. RumaRumah sakh sak! a"a#! a"a#ah Ruah Rumah Samah Sak! Bhak! Bha$a%$a%&ka'a&ka'aLumaLuma(a%&(a%&)) *.
*. SSu+ u+ KK,,mm!- !- MMuu!u !u PP',',--s s MM--""k k ++-'-'!u!u&&aas s mm-m-m/-/-'!'!ahahaa%%kaka% % kk,m,m/-/-!-!-%%ss "a%/',-s,%
"a%/',-s,%a#sm- s!a a#sm- s!a m-"s)m-"s) .
. TTm m P-P-#a#aksksa%a%a a AAu"u"! ! M-M-""k k a"a"a#a#ah ah !!m m $a$a%& %& ""+-+-%!%!uk uk "a"a% % ""!-!-!a!a/k/ka% a% ,#,#-h-h D
D'-'-k!k!uu'R'Rumumah ah SaSakk! ! u%u%!u!uk k m-m-m+m+a%a%!u !u SuSu+ + K,K,mm!- !- MuMu!u !u P'P',,-s-s M-M-""kk m-#aksa%aka% au"! m-"k. A%&&,!a !m /-#aksa%a au"! m-"k "s-suaka% "-%&a% m-#aksa%aka% au"! m-"k. A%&&,!a !m /-#aksa%a au"! m-"k "s-suaka% "-%&a% !-ma "a% !-m/a!
!-ma "a% !-m/a! /-#aksa%aa% au"! m-"k)/-#aksa%aa% au"! m-"k) .
. AAu"u"! ! m-m-""s s susuaa!u !u uu/a/a$$a a -2-2a#a#uuaas s s-s-3a3a'a 'a //',',--ss,,%a%a# # $$a%a%& & ""##akaksasa%a%akaka%% s-3a
s-3a'as'ass!-mas!-ma!k !k !-'ha!-'ha"a/ "a/ mu!u mu!u /-#/-#a$a%aa$a%a% % m-"m-"k k $a%& $a%& "+-"+-'ka% k-/a"a 'ka% k-/a"a /as/as-%-%
"-"-%&%&a%a%m-m-%&%&&u&u%a%akaka% % '-'-kakam m m-m-""k k $a$a%& %& ""#a#aksksa%a%akaka% a% ,#,#-h -h /'/',,-s-s m-m-""k4k4 "-%&a%m-#
"-%&a%m-#+a!ka% m!'a +a!ka% m!'a +-s!a' 5/--' &',u/6)+-s!a' 5/--' &',u/6) .
. SM8 a"a#SM8 a"a#ah k-#,mah k-#,m/,k s!a m-"/,k s!a m-"s $a%& k-as $a%& k-a%&&,%&&,!aa%%!aa%%$a s-su$a s-sua "-%&a "-%&a% /',-a% /',-s "a%s "a% k-ah#a%%$a)
k-ah#a%%$a)
6.
6. M!'a B-s!a' a"a#ah s-k-#,m/,k s!a m-"s "-%&a% '-/u!as "a% k,m/-!-%s/',-sM!'a B-s!a' a"a#ah s-k-#,m/,k s!a m-"s "-%&a% '-/u!as "a% k,m/-!-%s/',-s
$a%& +ak u%!uk m-%-#aah s-&a#a ha# $a%& !-'ka! "-%&a% /',-s m-"s. $a%& +ak u%!uk m-%-#aah s-&a#a ha# $a%& !-'ka! "-%&a% /',-s m-"s.
BAB II
RUANG LINGKUP
Da#am u/a$a m-m+-'ka% /-#a$a%a% /'ma k-/a"a /as-% maka /hak 'umahsak! ha'us !-'us m-%(a&a kua#!as k-'(a%$a. U%!uk m-%(a&a kua#!as !-'s-+u! 3a'a!-'+ak a"a#ah "-%&a% m-#aksa%aka% au"! m-"s s-3a'a +-'ka#a. D-%&a% "-mka%kua#!as #a$a%a% "a/a! "/a%!au "-%&a% aku'a!. Ham+a!a% "a% k-su#!a% s-#ama /',s-s/-#a$a%a% "a/a! ""-%!kas "-%&a% 3-/a! "a% m-%$-#u'uh. K-m-%!-'a% K-s-ha!a%(u&a m-ma%"a%& sa%&a! /-%!%& /-#aksa%aa% au"! m-"s s-3a'a +-'ka#a " 'umahsak!. M-#a#u K-/m-%k-s N,. 9: !ahu% *00 !-%!a%& Au"! M-"k "+-'ka%/-%(-#asa% $a%& #-%&ka/ ma%aa! "a% +a&ama%a /-#aksa%aa% au"! m-"s " 'umahsak!.
Tu(ua% /-#aksa%aa% au"! m-"k s-3a'a umum a"a#ah m-m/-'!aha%ka%k,m/-!-%s "a% /',-s,%a#sm- s!a m-"k "-%&a% m-#+a!ka% m!'a +-s!a'.S-"a%&ka% !u(ua% khusus /-#aksa%aa% au"! m-"k a"a#ah s-+a&a +-'ku! ;
1. M-#akuka% /-%#aa% !-'ha"a/ k,m/-!-%s s!a m-"k /-m+-' /-#a$a%a% "'umah sak!)
*. M-m+-'ka% k-<-%a%&a% k#%s 5clinical previlege6 s-sua k,m/-!-%s $a%&"m#k) . M-'-k,m-%"aska% /-%3a+u!a% a!au /-%a%&&uha% k-<-%a%&a% k#%s
5clinicalprevilege6)
. M-'-k,m-%"aska% /-'u+aha%= m,"kas '%3a% k-<-%a%&a% k#%s s-,'a%&s!a m-"k)
. M-#akuka% -2a#uas +-'k-s%am+u%&a% 5 on going professional practiceevaluation64 +ak s-3a'a /-','a%&a% mau/u% k-#,m/,k4 +-'"asa'ka% s!a%"a'/',-s a!au SPO $a%& !-#ah "+ua!.
Au"! m-"s m-'u/aka% peer review maka /-#aksa%aa%%$a <a(+ m-#+a!ka% k-#,m/,ks!a m-"s. S-+-#um%$a /hak 'umah sak! ha'us m-m+-%!uk !m /-#aksa%a au"!m-"s. Tm !-'s-+u! "a/a! "+-%!uk "+a<ah K,m!- M-"k a!au /a%!a khusus u%!uk!u. Ka'-%a au"! m-"s -'a! ka!a%%$a "-%&a% '-kam m-"s maka +a&a% '-kam m-"s(u&a ha'us "#+a!ka% "a#am !m.
BAB III TATA LAKSANA
Ka'umk! 'umah sak! m-%-!a/ka% k-+(aka% "a% /',s-"u' s-#u'uh m-ka%sm-k-'(aSu+ K,m!- Mu!u P',-s +-'"asa'ka% masuka% K,m!- M-"k. S-#a% !u Ka'umk!'umah sak! +-'!a%&&u%& (a<a+ a!as !-'s-"a%$a +-'+a&a sum+-' "a$a $a%&"+u!uhka% a&a' k-&a!a% % "a/a! !-'s-#-%&&a'a.
1. Au"! M-"s
Au"! M-"s "#aksa%aka% s-+a&a m/#-m-%!as u%&s ma%a(-m-% k#%s "a#am'a%&ka /-%-'a/a% !a!a k-#,#a k#%s $a%& +ak " 'umah sak!. Au"! m-"s !"ak"&u%aka% u%!uk m-%3a' a"a a!au !"ak%$a k-sa#aha% s-,'a%& s!a m-"s "a#amsua!u kasus. Da#am ha# !-'"a/a! #a/,'a% k-(a"a% "-%&a% "u&aa% k-#a#aa%s-,'a%& s!a m-"s4 $a%& "&u%aka% a"a#ah m-ka%sm-"s/#%/',-s4 +uka%%$a m-ka%sm- au"! m-"s. Au"! m-"s "#akuka% "-%&a%m-%&-"-/a%ka% '-s/-k !-'ha"a/ s-mua s!a m-"s 5no blaming culture6 "-%&a%3a'a !"ak m-%$-+u!ka% %ama 5no naming 64 !"ak m-m/-'sa#ahka% 5no blaming 6"a% !"ak m-m/-'ma#uka% 5no shaming 6.
Au"! m-"s $a%& "#akuka% ,#-h 'umah sak! a"a#ah k-&a!a% -2a#uas /',-ss-3a'a ss!-mk $a%& m-#+a!ka% m!'a +-s!a' 5 peer group6 $a%& !-'"' "a'k-&a!a% /--' >'-2-<4 su'2-##a%3- "a% ass-ssm-%! !-'ha"a/ /-#a$a%a% m-"s "'umah sak!.
Da#am /-%&-'!a% au"! m-"s !-'s-+u! "a!as4 'umah sak!4 K,m!- M-"k a!aumas%&?mas%& k-#,m/,k s!a m-"s "a/a! m-%$-#-%&&a'aka% -2a#uas k%-'(a/',-s $a%& !-',kus 5focused professional practice evaluation6.
S-3a'a umum4 /-#aksa%aa% au"! m-"s ha'us "a/a! m-m-%uh 5-m/a!6 /-'a%/-%!%&4 $a!u ;
a6 S-+a&a sa'a%a u%!uk m-#akuka% /-%#aa% !-'ha"a/ k,m/-!-%s mas%&mas%&s!a m-"s /-m+-' /-#a$a%a% " 'umah sak!)
+6 S-+a&a "asa' u%!uk /-m+-'a% k-<-%a%&a% k#%s 5clinical previllege6 s-suak,m/-!-%s $a%& "m#k)
36 S-+a&a "asa' +a& K,m!- M-"k "a#am m-'-k,m-%"aska% /-%3a+u!a% a!au/-%a%&&uha% k-<-%a%&a% k#%s 5 clinical previllege6) "a%
"6 S-+a&a "asa' +a& K,m!- M-"k "a#am m-'-k,m-%"aska% /-'u+aha% =m,"kas '%3a% k-<-%a%&a% k#%s s-,'a%& s!a m-"s.
Au"! m-"s "a/a! /u#a "s-#-%&&a'aka% "-%&a% m-#akuka% -2a#uas+-'k-s%am+u%&a% 5on-going professional practice evaluation64 +ak s-3a'a/-','a%&a% mau/u% k-#,m/,k. Ha# % "a/a! "#akuka% "-%&a% +-+-'a/a 3a'a4a%!a'a #a% "a/a! m-'u/aka% k-&a!a% $a%& +-'+-%!uk sk#us s-+a&a u/a$a/-'+aka% $a%& !-'us m-%-'us s-+a&ama%a !-'3a%!um " +a<ah % ;
B-'"asa'ka% sk#us "a!as maka #a%&kah?#a%&kah /-#aksa%aa% au"! m-"s"#aksa%aka% s-+a&a +-'ku! ;
a. P-m#ha% !,/k $a%& aka% "#akuka% au"!.
Taha/ /-'!ama "a' au"! m-"s a"a#ah /-m#ha% !,/k $a%& aka% "#akuka%au"!. P-m#ha% !,/k !-'s-+u! +as +-'u/a /-%a%&&u#a%&a% /-%$ak! !-'!-%!u "'umah sak! 5msa#%$a ; !h$/us a+",m%a#s64 /-%&&u%aa% ,+a! !-'!-%!u5msa#%$a ; /-%&&u%aa% a%!+,!k64 !-%!a%& /',s-"u' a!au !%"aka% !-'!-%!u4!-%!a%& %-ks %,s,k,ma# " 'umah sak!4 !-%!a%& k-ma!a% ka'-%a /-%$ak!!-'!-%!u4 "a% #a%?#a%. P-m#ha% !,/k % sa%&a! /-%!%&. Da#am m-m#h !,/ka&a' m-m/-'ha!ka% (um#ah kasus a!au -/"-m,#,& /-%$ak! $a%& a"a "'umah sak! "a% a"a%$a k-%&%a% u%!uk m-#akuka% /-'+aka%. S-+a&a 3,%!,h" 'umah sak! kasus !h$/us
M-%&ama!P
'ak!k
M-m+a%"%&ka%"
-%&a%S!a%"a'
M-%-'a/ka%P
-'+aka%
M-%-'a/ka%S
!a%"a'
M-m#hT,
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a+",m%a#s 3uku/ +a%$ak "-%&a% a%&ka k-ma!a%3uku/ !%&&. Ha# % !-%!u%$a m-%(a" masa#ah "a% %&% "#akuka% /-'+aka%.P-m#ha% "a% /-%-!a/a% !,/k a!au masa#ah $a%& %&% "#akuka% au"! "/#h+-'"asa'ka% k-s-/aka!a% K,m!- M-"k "a% k-#,m/,k s!a m-"s.
+. P-%-!a/a% s!a%"a' "a% k'!-'a.
S-!-#ah !,/k "/#h maka /-'#u "!-%!uka% k'!-'a a!au s!a%"a' /',-s $a%&(-#as4 ,+$-k! "a% '%3 !-'ka! "-%&a% !,/k !-'s-+u!. Msa#%$a !,/k $a%& "/#h!h$/us a+",m%a#s maka /-'#u "!-!a/ka% /',s-"u' /-m-'ksaa%4 "a&%,ss "a%/-%&,+a!a% !h$/us a+",m%a#s. P-%-!a/a% s!a%"a' "a% /',s-"u' % ,#-h m!'a+-s!a' 5 peer group6 "a%=a!au "-%&a% ka!a% /',-s s-!-m/a!. A"a "ua #-2-#s!a%"a' "a% k'!-'a $a!u must do $a%& m-'u/aka% a+s,#u!- m%mum k'!-'a"a% should do $a%& m-'u/aka% !am+aha% k'!-'a $a%& m-'u/aka% has#/-%-#!a% $a%& +-'+ass +uk!.
3. P-%-!a/a% (um#ah kasus=sam/-# $a%& aka% "au"!
Da#am m-%&am+# sam/-# $a%& +sa "-%&a% m-%&&u%aka% m-!,"-/-%&am+#a% sam/-# !-!a/ +sa (u&a "-%&a% 3a'a s-"-'ha%a $a!u m-%-!a/ka%kasus !h$/us a+",m%a#s $a%& aka% "au"! "a#am ku'u% <ak!u !-'!-%!u4msa#%$a "a' +u#a% Ja%ua' sam/a Ma'-!. Msa#%$a s-#ama +u#a% !-'s-+u!a"a *00 kasus maka *00 kasus !-'s-+u! $a%& aka% "#akuka% au"!.
". M-m+a%"%&ka% s!a%"a'=k'!-'a "-%&a% /-#aksa%aa% /-#a$a%a%
Su+ K,m!- Mu!u P',-s a!au Tm P-#aksa%a Au"! M-"s m-m/-#a(a' '-kamm-"s u%!uk m-%&-!ahu a/akah k'!-'a a!au s!a%"a' "a% /',s-"u' $a%& !-#ah"!-!a/ka% !a" !-#ah "#aksa%aka% a!au !-#ah "3a/a "a#am masa#ah a!aukasus? kasus $a%& "/-#a(a'. Da!a !-%!a%& kasus?kasus $a%& !"ak m-m-%uhk'!-'a $a%& !-#ah "!-!a/ka% "/sahka% "a% "kum/u#ka% u%!uk "a%a#ss.Msa#%$a "a' *00 kasus a"a *0 kasus $a%& !"ak m-m-%uh k'!-'a a!aus!a%"a' maka *0 kasus !-'s-+u! a&a' "/sahka% "a% "kum/u#ka%.
-. M-#akuka% a%a#ss kasus $a%& !"ak s-sua s!a%"a' "a% k'!-'a.
Su+ K,m!- Mu!u P',-s a!au !m /-#aksa%a au"! m-"s m-%$-'ahka% k-*0kasus !-'s-+u! /a"a m!'a +-s!a' 5 peer group6 u%!uk "%#a #-+h #a%(u!. Kasus? kasus!-'s-+u! "a%a#ss "a% ""skuska% a/a k-mu%&k%a% /-%$-+a+%$a "a%m-%&a/a !-'(a" k-!"aks-suaa% "-%&a% s!a%"a'. Has#%$a ; +sa (a" !-'"a/a!5msa#%$a6 1 kasus $a%& /-%$m/a%&a%%$a !-'ha"a/ s!a%"a'
a"a#aha33-/!a+#- ka'-%a /-%$u#! a!au k,m/#kas $a%& !ak !-'"u&a s-+-#um%$a5unforeseen6. K-#,m/,k % "s-+u! "-2as 5$a%& acceptable6. Ssa%$a $a%& kasus a"a#ah "-2as $a%& unacceptable4 "a% ha# % "ka!aka% s-+a&a"-s-%s. U%!uk m-#akuka% a%a#ss kasus !-'s-+u! a/a+#a "/-'#uka% "a/a!m-%&u%"a%& k,%su#!a% !amu a!au /aka' "a' #ua'4 $a%& +asa%$a "a' 'umahsak! /-%""ka%.
. M-%-'a/ka% /-'+aka%.
M!'a +-'s!a' 5 peer group6 m-#akuka% !%"aka% k,'-k! !-'ha"a/ k-#ma kasus$a%& "-s-%s !-'s-+u! s-3a'a k,#-&a#4 "a% m-%&h%"a' @ blaming culture. Ha#% "#akuka% "-%&a% m-m+ua! '-k,m-%"aas u/a$a /-'+aka%%$a4 3a'a? 3a'a/-%3-&aha% "a% /-%a%&&u#a%&a%4 m-%&a"aka% /',&'am /-%""ka% "a%#a!ha%4 /-%$usu%a% "a% /-'+aka% /',s-"u' $a%& a"a "a% #a% s-+a&a%$a.
&. R-%3a%a au"! s-#a%(u!%$a.
M-m/-#a(a' #a& !,/k $a%& sama " <ak!u k-mu"a%4 msa#%$a s-!-#ah :5-%am6 +u#a% k-mu"a%. Tu(ua% '-au"! "#aksa%aka% a"a#ah u%!uk m-%&-!ahua/akah su"ah a"a u/a$a /-'+aka%. Ha# % +uka% +-'a'! !,/k au"! a"a#ahsama !-'us m-%-'us4 au"! $a%& "#akuka% : 5-%am6 +u#a% k-mu"a% % #-+hu%!uk m-#ha! u/a$a /-'+aka%. Namu% sam+# m-#ha! u/a$a /-'+aka% %4 Su+K,m!- Mu!u P',-s a!au !m /-#aksa%a au"! "a% m!'a +-s!a' 5 peer group6"a#am m-m#h !,/k #a%.
P-#aksa%a k-&a!a% au"! m-"s 'umah sak! "a/a! "#akuka% ,#-h K,m!- M-"s m-#a#uSu+ K,m!- Mu!u P',-s $a%& k-mu"a% m-m+-%!uk /a%!a au"! m-"s4 "-%&a%m-#+a!ka% +a&a% '-kam m-"s "a% k-#,m/,k s!a m-"s. Au"! m-"s ha'us "#aksa%aka%"-%&a% /-%uh !a%&&u%& (a<a+ u%!uk m-%%&ka!ka% mu!u /-#a$a%a% +uka% u%!ukm-%$a#ahka% a!au m-%&hakm s-s-,'a%&4 ha'us "#aksa%aka% s-3a'a ,+(-k!4%"-/-%"-% "a% m-m/-'ha!ka% as/-k k-'ahasaa% /as-% "a% <a(+ sm/a% 'ahasak-",k!-'a%. A%a#ss has# au"! m-"s ha'us "#akuka% ,#-h k-#,m/,k s!a m-"s !-'ka!$a%& m-m/u%$a k,m/-!-%s4 /-%&-!ahua% "a% k-!'am/#a% s-sua "-%&a% +"a%&/-#a$a%a% "a% a!au kasus $a%& "au"!
BAB IV DOKUMENTASI
1. B-'kas R-kam M-"k) *. 8,'m P-",ma% Au"!)
. 8,'m R%&kasa% Da!a Au"!) . 8,'m K-'!as K-'(a Pa%!a) . 8,'m A%a#ss K-ku'a%&a%)
:. 8,'m T%"aka% "a% T%"ak La%(u!) 7. Da!a' ha"'.
S-#a% Au"! M-"k4 Su+ K,m!- Mu!u P',-s (u&a m-#aksa%aka% ; 1. M-'-k,m-%"aska% P-%""ka% B-'k-#a%(u!a% Ba& S!a M-"s.
a6 Su+ K,m!- Mu!u P',-s m-%-%!uka% /-'!-mua%?/-'!-mua% #mah $a%& ha'us"#aksa%aka% ,#-h mas%&?mas%& k-#,m/,k s!a m-"s "-%&a% /-%&a!u'a%/-%&a!u'a%<ak!u $a%& "s-suaka%.
+6 P-'!-mua% !-'s-+u! "a/a! /u#a +-'u/a /-m+ahasa% kasus !-'s-+u! a%!a'a #a%m-#/u! kasus k-ma!a% 5death case64 kasus su#! mau/u% kasus #a%&ka. 36 S-!a/ /-'!-mua% #mah ha'us "s-'!a %,!u#-%s4 k-sm/u#a% "a% "a!a'
ha"'/-s-'!a $a%& aka% "(a"ka% /-'!m+a%&a% "a#am /-%#a% "s/#% /',-s.
"6 N,!u#-%s +-s-'!a "a!a' ha"' m-%(a" ",kum-%=a's/ "a' Su+ K,m!-Mu!uP',-s.
-6 Su+ K,m!- Mu!u P',-s +-'sama?sama "-%&a% k-#,m/,k s!a m-"sm-%-%!uka% k-&a!a%?k-&a!a% #mah $a%& aka% "+ua! ,#-h Su+ K,m!- Mu!uP',-s $a%& m-#+a!ka% s!a m-"s 'umah sak! s-+a&a %a'asum+-' "a%/-s-'!a ak!.
6 S-!a/ k-#,m/,k s!a m-"s m-%-%!uka% m%ma# sa!u k-&a!a% #mah $a%&aka% "#aksa%aka% "-%&a% Su+ K,m!- Mu!u P',-s /-' !ahu%.
&6 Su+ K,m!- Mu!u P',-s +-'sama "-%&a% +a&a% /-%""ka% "a% /-%-#!a%'umah sak! m-mas#!as k-&a!a% !-'s-+u! "a% "-%&a% m-%&usahaka% sa!ua%a%&ka k'-"! "a' ka!a% /',-s.
h6 Su+ K,m!- Mu!u P',-s m-%-%!uka% k-&a!a%?k-&a!a% #mah $a%& "a/a!"ku! ,#-h mas%&?mas%& s!a m-"s s-!a/ !ahu% "a% !"ak m-%&u'a%& ha'3u! !ahu%a%%$a.
6 Su+ K,m!- Mu!u P',-s m-m+-'ka% /-'s-!u(ua% !-'ha"a/ /-'m%!aa% s!am-"s s-+a&a asu/a% k-/a"a "'-ks.
*. M-mas#!as P',s-s P-%"am/%&a% 5Proctoring 6 +a& S!a M-"s $a%& m-m+u!uhka%.
a6 Su+ K,m!- Mu!u P',-s m-%-%!uka% %ama s!a m-"s $a%& aka% m-%"am/%&s!a m-"s $a%& s-"a%& m-%&a#am sa%ks "s/#%=m-%"a/a!ka% /-%&u'a%&a%clinical privilege.
b) K,m!- M-"k +-'k,,'"%as "-%&a% Ka'umk! Rs Bha$a%&ka'au%!uk m-mas#!as s-mua sum+-' "a$a $a%& "+u!uhka% u%!uk /',s-s/-%"am/%&a% 5 proctoring) !-'s-+u!.
