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'(U Memahami tanggung )awa* RS
se*agai penyedia pelayanan yang
mem+!"us"an "epada "e*utuhandan harapan pasien terhadappelayanan di RS
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'( Dapat men)elas"an tentang
"eselamatan pasien selama
menerima pelayanan di RS Dapat memahami medi-al err!r di
RS dan *agaimana -ara
pen-egahan terhadap medi-alerr!r
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'( -!ntinued/ Dapat memahami sistem
mana)emen mutu, untu" men)aga
mutu pelayanan di RS Dapat memahami )enis pelayanan
yang ada di RS Dapat memahami, mengidenti0"asi,
dan menganalisa peran pasiense*agai mitra dlm pelayanan"esehatan di RS
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'! Err is 1umanKohn LT,
Corrigan JM,Donaldson MS, Eds. To
Err Is Human.Washington NationalPress, Wash, DC.2000.
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Apa"ah 2Medi-ati!n Err!r34 Medication Error adalah kejadian yang
dapat dicegah yang dapat
menyebabkan penggunaan medikasiyang tidak tepat (inappropriate) atau
mencelakakan pasien, pada saat
medikasi itu dikendalikan oleh paraprofesional kesehatan, pasien, atau
konsumer.
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Apa"ah 2Medi-ati!n Err!r34Kejadian tersebut berhubungan dengan:
pra"te" pr!+esi!nal
pr!du" perawatan "esehatan
pr!sedur and sistem
pr!du-t la*eling, pa-"aging, andn!men-lature
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Apa"ah 2Medi-ati!n Err!r34
#/ dispensing
Distri*usi
(enyerahan administrati!n/
edu"asi
(emantauan m!nit!ring/
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Apa"ah 2Medi-ati!n Err!r34 esalahan yang di*uat !leh d!"ter,
perawat, ap!te"er, -aregi5er, atau
pasien selama dalam pr!sesperesepan, pem*erian, penyerahanatau penggunaan !*at. (enye*a*tersering adalah nama6nama !*atyang mirip Benylin and Benadryl/"emasan, la*el dan peresepan yangmirip.
(RE7E8'I89 MEDICA'IO8 ERRORS: A 7ital (re-auti!n ;r!m the *!!": 1!w '!9et 'he Best Medi-al Care By Dr.Aniruddha Malpani and Dr.An)ali Malpani
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Bila in+!rmasinya seperti ini,
apa"ah Anda mau nai" pesawat4
xtra xtra
Airlines expect 1-2
jets to crash dailyebih !""" kematian#minggu
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Bagaimana dengan men)adi pasiendalam sistem "esehatan4
xtra xtra
Airlines expect 1-2 jets to
crash daily
Over 1000 deaths expected
weekly
$
Kohn et al. Committee on qalit! health "are in #meri"a. $%M. #"adem!
xtra xtra
Airlines expect 1-2 jets to
crash daily
Lebih dari 1000
kematian/mingg
$((,000 )'*,000
Kematian+tah
n ai-atmedi"al errors
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Errorsare costlyin terms of loss
of trustin the health care systemby patients and diminished
satisfactionby both patients and
health professionals
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%ccidents!&',"
MedicalErrors*!"","""
%l+heimers-,'&
iabetes
!,'/&www!cdc! ov/nchs/"astats! Accessed #an 2012! $ased on 200% data!
Rang"ing Medi-al Err!rsse*agai (enye*a* ematian
0eart!,"
1ancer2&,/2
3troke!'2,42&
ung
!&,4&-
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(enye*a* Medi-al Err!r
5&omnikasi brk dalam tim kesehatan5'erintah verbal
5tlisan tangan yang jelek/tidak terbaca
5'emilihan obat yang tidak tepat
5(edikasi yang )missing*
5'enjadalan yang tidak tepat
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(enye*a* Medi-al Err!r #/
5look alike / sond alike drgs
5poli"armasi
5availability o" "loor stock +no second check,
5nteraksi obat
5hectic work environment
5lack o" compter decision spport
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Tie Error/ Diagnosti Err!r atau "eterlam*atan dalam
diagn!sis.
egagalan untu" mengguna"an u)i6u)iyang sesuai indi"asi.
(enggunaan u)i atau terapi yangsudah "un!.
egagalan untu" *ertinda" sesuaihasil dari u)i pemeri"saan danpemantauan.
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Tie Error/ Treatmen Err!r dalam pela"sanaan !perasi,
pr!sedur, atau u)i pemeri"saan.
Err!r dalam pem*erian treatment Err!r dalam d!sis dan met!de
penggunaan !*at eterlam*atan treatmen yang
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Tie Error/ Preenti1 egagalan untu" menyedia"an
treatmen pr!0la"ti"
(emantauan atau +!ll!w6up dalamtreatmen yang inade"uat
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8/9/2019 Medical Error 2015
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Classi+ying medi-ati!n err!rs
A circmstances exist "or potential errors to occr
$ an error occrred bt did not reach the patient
error reached the patient bt did not case harm
patient monitoring re3ired to determine lack o" harm
error cased temporary harm and some intervention
4 temporary harm with initial or prolonged hospitali5ation
6 error reslted in permanent patient harm
7 error re3ired intervention to sstain the patient*s li"e
error contribted to the patient*s death
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More commonly, errors are
caused by faulty systems,processes, and conditionsthat
lead people
to make mistakes or
fail to prevent them.
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Strateg! 1or$mroement
Esta-lishing a national 1o"s to"reate leadershi, resear"h,
tools, and roto"ols toenhan"e the no3ledge -asea-ot sa1et!.
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Strateg! 1or$mroement
$denti1!ing and learning 1romerrors -! deeloing a
nation3ide -li" mandator!reorting s!stem and -!en"oraging health "are
organi4ations and ra"titionersto deelo and arti"iate inolntar! reorting s!stems.
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Strateg! 1or$mroement
5aising er1orman"e standardsand e6e"tations 1or
imroements in sa+ety thr!ughthe a-ti!ns !+ !5ersight!rganiati!ns, pr!+essi!nalgr!ups,
and gr!up pur-hasers !+ health-are.
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Strateg! 1or$mroement
$mlementing sa1et! s!stemsin health "are organi4ations to
ensre sa1e ra"ti"es at thedelier! leel
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Health care is a decade or more
be-hind many other high-riskindustries in its attention to
ensuring basic safety.
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Voluntary reporting systems will
provide an important complementto the mandatory system.
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The process of developing and
adopting standards also helpsto form expectations for safety
among providers and consumers
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Medication errors now occur
freuently in hospitals,yet many hospitals are not making use
of known systems for improving
safety!
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"ith adeuate
leadership,attention,
and resources,
improvements canbe made.
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