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ADVERSE EVENT (kejadian tidak diharapkan)
(KTD)
Wirsma Arif Harahap Surgical Oncologist
PRIMUM, NON NOCERE FIRST, DO NO HARM
HIPPOCRATES’S TENET
(460-335 BC)
What I want to talk about
“Freedom from accidental injury due to medical care, or medical errors” –
Institute of Medicine 1999
What I want to talk about
A story
How common is adverse event?
Why does it happen?
How should we think ?
How should we respond?
“Mistakes are a fact of life. It’s the response
to the error that counts”
- Nikki Giovanni
Florida Annual Accidental Deaths,
2003
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Medical Auto Workplace Air
Deaths
5th leading cause
9th leading cause
How hazardous is health care?
1
10
100
1,000
10,000
100,000
1 10 100 1,000 10,000 100,000 1,000,000 10,000,000
Number of encounters for each
fatality
To
tal lives l
ost
per
year
REGULATED DANGEROUS
(>1/1000)
ULTRA-SAFE
(<1/100K) Health Care
Mountain Climbing
Bungee Jumping
Driving
Chemical Manufacturing
Chartered Flights
Scheduled Airlines
European Railroads
Nuclear Power
Note: both dimensions are logarithmic
scales
DATA KASUS DUGAAN MALPRAKTIK YANG SUDAH DILAPORKAN
1. 12 -02-04 Alm. Lucy Maywati RS Bersalin YPK Jkt Meninggal saat melahirkan caecar Polda Metro Jaya
Tgl Korban Terlapor Kasus Lapor
2. 23-04-04 Wulan Yulianti RSCM Jkt Meninggal krn operasi pd usus Polda Metro Jaya
3. 28 -04-04 Alm Lucy Maywati RS Bersalin YPK Jkt Penggelapan M/R Polda Metro Jaya
4. 07-06-04 Jeremiah RS Budi Lestari Bks Operasi caecar mengakibatkan Polda Metro Jaya RS Hermina, Bekasi luka & cacat
5. 11 -06-04 Mindo Sihombing RS Persahabatan Jkt Gagal operasi hernia Polda Metro Jaya
6. 15-06-04 Anissa Safitri RSCM Jkt Hidrocepalus Polda Metro Jaya
7. 24 -06-04 Alm. Jajang RSUD Sukabumi Jabar Wabah malaria di Sukabumi Polda Jawa Barat
8. 30-06-04 Alm. Lucy Maywati RS Bersalin YPK Jkt Meninggal saat melahirkan Polda Metro Jaya
9. 07 -07-04 Robinson L. Tobing RS Kodam Bkt Barisan Vegetativ State akibat operasi/ Polda Sumatra Medan cacat permanen Utara
10. 12-07-04 Anissa Safitri Yayasan Amal Beduli Perbuatan tdk menyenangkan Polda Metro Jaya Seribu, Jkt krn memulangkan pasien
11. 08 -07-04 Ngatmi RS Persahabatan Jkt Operasi kanker payudara Polda Metro Jaya
12. 14-07-04 Rohati RS Darmais Jkt Meninggal dunia akibat gagal Polda Metro Jaya operasi kanker payudara
13. 18 -07-04 Dr Jane P PT Newmont Minahasa Pencemaran limbah B3 Mabes Polri Raya, Sulawesi Utara
14. 18-07-04 Srifika Modeong RS CM & RS MMC Jkt Keracunan mercury & arsen Mabes Polri
15. 18 -07-04 Rasyid Rahman RS CM & RS MMC Jkt Keracunan mercury & arsen Mabes Polri
16. 18-07-04 Juhria Ratubahe RS CM & RS MMC Jkt Keracunan Mercury & arsen Mabes Polri
17. 18 -07-04 Masna Stiman RS CM & RS MMC Jkt Keracunan mercury & arsen Mabes Polri
18. 26-07-04 Revy Anastasia RS Cikini Jkt Keracunan Obat Polda Metro Jaya
19. 09 -07-04 Revy Anastasia Apotik RS Cikini Jkt Keracunan Obat Polda Metro Jaya
20. 12-08-04 Rasyid Rahman Menkes Ahmad Sujudi Pencemaran nama baik dgn Mabes Polri Mentamben P Yusgiantoro menyatakan tdk ada pencemaran Men LH Nabiel Makarim
21. 18 -08-04 Fellina Azzahra RS Karya Medika Jkt Meninggal krn salah operasi usus Polda Metro Jaya
22. 31-08-04 Again Isna Nauli RS Islam Bogor Kelalaian medis yg berakibat SATGA OPS Polda cacat permanen Jawa Barat
23. 03 -09-04 Anggi & Anggeli RSCM Jkt Membiarkan pasien yg hrs dirawat Polda Metro Jaya
24. 03-09-04 Andreas RS Pasar Rebo Jkt Kelahiran yg mengakibatkan cacat Polda Metro Jaya
25. 03 -09-04 Maena Nurrocmah RS Setia Mitra Jkt Operasi usus Polda Metro Jaya
26. 15-09-04 Fellina Azzahra RS K Medika Cibitung Meninggal krn operasi usus Polda Metro Jaya RSCM Jkt
27. 16-09-04 Leonardus W Pete RS Silom Gleaneglas Penyaderaan krn tdk mampu byr Polda Metro Jaya
28. 27-09-04 Wino Polres Sorong Papua Penganiayaan mengakibatkan Mabers Polri Wiran mata dan dada rusak parah
29. 28-09-04 Lexyano Hamsalim RS Medistra Jkt Infeksi akibat operasi klip jantung Polda Metro Jaya
30. 28-09-04 Parrel Davin H.A RS Eva Sari Lalai mengakibtakan org lain Polda Metro Jaya Sinurat Rawamangun Jkt meninggal
31. 05-10-04 Rizka Hudha RS Harapan Bunda Jkt Lalai mengakibatkan kematian Polda Metro Jaya
32. 05-10-04 Masita Ariani Klinik Bedah Plastik Kegagalan bedah plastik pd hidung Dit Reskrim Polda (Annisa) Bandung Jawa Barat
33. 07-10-04 Tyava Putra Juliarty Klinik Dharma Bakti 2 Keracunan obat mengakibatkan Polda Metro Jaya RS harapan Kita Jkt Steven Johnson Syndrom
34. 20-10-04 Chealfiro M.P RSCM Jkt Operasi Hemia Polda Metro Jaya
35. 20-10-04 Sahat Parulian RS Cikini Jkt Pencemaran nama baik Polda Metro Jaya
36. 06-11-04 Fatimah RSCM Jkt Kelalaian mengakibatkan kematian Polda Metro Jaya
37. 10-11-04 Panca Satriya Dr. Siti Fadillah S Dugaan tindak pidana membuat Mabes Polri Hasan Kesuma (Menkes RI) perasaan tdk menyenangkan
38. 14-01-05 Siti Zulaeha RSUD Pasar Rebo Jkt Kesalahan dlm operasi Polda Metro Jaya
39. 16-02-05 Selli Wane Carolina RS Fatmawati Jkt Kesalahan dlm operasi pd tulang Polda Metro Jaya belakang berakibat cacat
40. 24-02-05 Martha Manulang RS St Carolus Jkt Salah obat Polda Metro Jaya
41. 11-03-05 Chris RS Sumber Waras Jkt Kesalahan dlm operasi Polda Metro Jaya RS Mitra Kemayoran Jkt
42. 11-03-05 Tumi RS Harun Jkt Kesalahan dlm operasi Polda Metro Jaya
43. 11-03-05 Erwin Said dr. GW Sp.B Pelaku tanpa seizin korban SIAGA OPS mengambil ginjal korban Bandar Lampung
44. 12-05-05 Royke Bagalutu, SH Rosyid Rusdi Melarang membawa anak ke SATGAS OPS Jabar Sandino Brata RS Hasan Sadikin Bandung (Asisten I Sukabumi)
45. 26-05-05 Royke Bagalatu, SH PT BIO FARMA Indo Pemberian vaksin polio yg tdk SATGAS OPS Jabar diakui WHO
46. 12-06-05 Nabila Ka Dinkes Jabar Anaknya kejang2, panas berak2 Polda Metro Jaya Dinkes Depok setelah imunisasi polio, kmd Menkes RI meninggal PT Bio Farma Indonesia
47. 18 -06-05 Wagirin RS Pelabuhan Kelalaian Medis Polda Metro Jaya
Sumber : Dari berbagai sumber BUHAROYAN NADAPDAP SH
Similar Vials: Cefazolin (antibiotic)
and Vecuronium (paralyzing agent)
Acceptable?
Health care is a highly complex, error prone industry.
Medicine is not a hard science … combination of art and practice
Aviation and Nuclear arms = High Reliability Organizations – strong safety record
Wasn’t always like that….
Swiss Cheese Model of Accident Causation
Modified from Reason, 1991 © 1991, James Reason
Triggers
DEFENSES
Accident
Regulatory
Narrowness
Incomplete
Procedures Mixed
Messages
Production
Pressures Responsibility
Shifting
Inadequate
Training
Attention
Distractions
Deferred
Maintenance
Clumsy
Technology LATENT
FAILURES
Goal Conflicts
and Double Binds
The World
KESALAHAN MEDIS (Medical Error)
Kesalahan yang terjadi dalam proses
asuhan medis yang mengakibatkan atau berpotensi mengakibatkan cedera pada
pasien.
(KKP-RS)
Medical errors are associated with
inexperienced clinicians, new procedures,
extremes of age, complex care and urgent
care. Poor communication, improper
documentation, illegible handwriting,
inadequate nurse-to-patient ratios, and
similarly named medications are also
known to contribute to the problem.
Patient actions may also contribute
significantly to medical errors.
Example for M Error
Misdiagnosis
Giving the wrong drug or (wrong patient, wrong chemical, wrong dose, wrong time, wrong route)
Giving two or more drugs that interact unfavorably or cause poisonous metabolic byproducts
Wrong site surgery such as amputating the wrong limb
Defenition
Adverse effect is a harmful and
undesired effect resulting from a
medication or other intervention
KEJADIAN TIDAK DIHARAPKAN (KTD)/ Adverse Event
Suatu kejadian yang mengakibatkan
cedera yang tidak diharapkan pada
pasien karena suatu tindakan (commission) atau karena tidak bertindak (ommision), dan bukan
karena “underlying disease” atau kondisi pasien (KKP-RS).
Adverse effects of medical procedures
Surgery may have a number of
undesirable or harmful after effects,
such as infection, hemorrhage,
inflammation, scarring,
high intensity radiotherapy may cause
burns and alterations in the skin.
Adverse effects of drugs
Drug interaction
Drug safety
Dose
Iatrogenesis is almost exclusively
used to refer to a state of ill health or
adverse effect or complication caused
by or resulting from medical
treatment.
Side-effect" (when judged to be
secondary to a main or therapeutic
effect) and may result from an
unsuitable or incorrect dosage or
procedure
Complication, in medicine, is an
unfavorable evolution of a disease, a
health condition or a medical
treatment.
Medical malpractice is an act or
omission by a health care provider
which deviates from accepted
standards of practice in the medical
community and which causes injury
to the patient. Simply put, medical
malpractice is professional negligence
(by a healthcare provider) that causes
an injury.
A near miss is an unplanned event
that did not result in injury, illness, or
damage - but had the potential to do
so.
NYARIS CEDERA (NC)/ Near Miss
Suatu kejadian akibat melaksanakan suatu
tindakan (commission) atau tidak mengambil
tindakan yang seharusnya diambil (omission),
yang dapat mencederai pasien, tetapi cedera
serius tidak terjadi, karena :
“keberuntungan”(mis.,pasien terima suatu
obat kontra indikasi tetapi tidak timbul reaksi obat)
“pencegahan” (suatu obat dengan overdosis
lethal akan diberikan, tetapi staf lain mengetahui dan membatalkannya sebelum obat diberikan)
“peringanan” (suatu obat dengan over dosis
lethal diberikan, diketahui secara dini lalu diberikan antidotenya).(KKP-RS)
Medical Error
Pasien
tidak cidera
Pasien
cidera
Near Miss
Adverse Event
(NM)
(AE)
Proses of Care
(Non Error) Adverse Event
Pasien
cidera
(KTD=Kejadian Tdk Diharapkan)
Nico A. Lumenta/KKP-RS
- Dpt obat “c.i.”, tdk timbul (chance)
- Plan, diket, dibatalkan (prevention)
- Dpt obat “c.i.”, diket, beri anti-nya
(mitigation)
Why do errors happen?
All humans make errors: indeed, “the ability to make mistakes” allows human beings to function
Most of medicine is complex and uncertain
Most errors result from “the system”
Healthcare has not tried to make itself safe
How to think of error?
An individual failing Only the minority of cases amount from
negligence or misconduct; so it’s the “wrong” diagnosis
Doctors will hide errors
May destroy many doctors inadvertently (the second victim)
A systems failure
This is the starting point for redesigning the system and reducing error
How to respond? Tactics
Reduce complexity
Optimise information processing
checklists, reminders, protocols
Automate wisely
Use constraints
for instance, with needle connections
Mitigate the unwanted side effects of change
with training, for example.
The Pathway to Increased Patient
Safety
Performance
Improvement
Projects
Cultural &
Process
Change
Data
Analysis
Healthcare
Incident
Investigation Team Event
Reporting
Tool
Questions?
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