la anev krs jan 2016
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POLRI DAERAH JAWA TIMUR
BIDANG KEDOKTERAN DAN KESEHATAN
RS. BHAY. WAHYU TUTUKO BOJONEGORO
LAPORAN ANALISA DAN EVALUASI STANDAR KESELAMATAN PASIEN RUMAH
SAKIT BHAYANGKARA TK. IV WAHYU TUTUKO BOJONEGORO
BULAN JANUARI 2016.
I. PENDAHULUAN
Pelayanan kesehatan a!a !asa"nya a!alah #nt#k $enyela$atkan as%en ses#a% !en&an
yan& !%#'akan H%"('"ates k%"a)k%"a *+,, tah#n yan& lal# ya%t# Primum, non nocere (First, do
no bsrat; Na$#n !%ak#% !en&an se$ak%n -e"ke$-an&nya %l$# !an tekn(l(&% elayanan
kesehatan kh#s#snya !% "#$ah sak%t $ena!% se$ak%n k($leks !an -e"(tens% te"a!%nya
Kea!%an T%!ak D%ha"akan ) KTD (Adverse event) aa-%la t%!ak !%lak#kan !en&an hat%)hat%.
D% "#$ah sak%t te"!aat "at#san $a'a$ (-at/ "at#san tes !an "(se!#"/ -anyak alat
!en&an tekn(l(&%nya/ -e"$a'a$ en%s tena&a "(tes% !an n(n "(tes% yan& s%a $e$-e"%kan
elayanan as%en *+ a$ te"#s $ene"#s. Ke-e"a&a$an !an ke"#t%nan elayanan te"se-#t
aa-%la t%!ak !%kel(la !en&an -a%k !aat te"a!% KTD.
Pa!a tah#n *,,, Institute of Medicine !% A$e"%ka Se"%kat $ene"-%tkan la("an yan&
$en&a&etkan -anyak %hak0 "TO ERR IS !MA", #!I$din% a Safer ea$t& S'stem
La("an %t# $en&e$#kakan enel%t%an !% "#$ah sak%t !% Utah !an 1(l("a!( se"ta Ne2Y("k. D%
Utah !an 1(l("a!( !%te$#kan KTD (Adverse Event; se-esa" */3 4/ !%$ana 5/5 4
!%anta"anya $en%n&&al. Se!an&kan !% Ne2 Y("k KTD a!alah se-esa" 6/7 4 !en&an an&ka
ke$at%an 86/5 4.An&ka ke$at%an ak%-at KTD a!a as%en "a2at %na !% sel#"#h A$e"%ka yan&
-e"#$lah 66/5 #ta e" tah#n -e"k%sa" ++.,,, ) 39.,,, e" tah#n. P#-l%kas% WHO a!a tah#n
*,,+/ $en$#lkan an&ka)an&ka enel%t%an "#$ah sak%t !% -e"-a&a% Ne&a"a0 A$e"%ka/
In&&"%s/ Den$a"k/ !an A#st"al%a/ !%te$#kan KTD !en&an "entan& 6/* )85/5 4. Den&an !ata)
!ata te"se-#t/ -e"-a&a% ne&a"a se&e"a $elak#kan enel%t%an !an $en&e$-an&kan S%ste$
Kesela$atan Pas%en.
Men&%n&at kesela$atan as%en s#!ah $ena!% t#nt#tan $asya"akat $aka elaksanaan
"(&"a$ kesela$atan as%en "#$ah sak%t e"l# !%lak#kan. Ka"ena %t# !%e"l#kan a'#an yan&
elas #nt#k $elaksanakan kesela$atan as%en te"se-#t. Pe!($an Kesela$atan Pas%en
R#$ah Sak%t yan& te"#ta$a -e"%s% Stan!a" Kesela$atan Pas%en R#$ah Sak%t !an T##h
Lan&kah Men## Kesela$atan Pas%en R#$ah Sak%t !%ha"akan !aat $e$-ant# "#$ah sak%t
!ala$ $elaksanakan ke&%atannya.
1. Maksu a! Tu"ua!Maks#! !an t##an !%lak#kannya Pe$-#atan La("an Anal%sa Dan E:al#as%
Stan!a" Kesela$atan Pas%en R#$ah Sak%t Bhayan&ka"a Tk.I; Wahy# T#t#k(
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B((ne&("( B#lan Jan#a"% *,85/ ya%t# $en&etah#% !an $en&anal%sa %n!%kat(")
%n!%kat(" !ala$ stan!a" kesela$atan as%en seh%n&&a $en%n&katkan
kesela$atan as%en !an $e$%n%$alkan an&ka ke$at%an as%en !% R#$ah
Sak%t Bhayan&ka"a Wahy# T#t#k( B((ne&("(.
2. Dasa#
a. Un!an&)Un!an& N($(" * Tah#n *,,* tentan& Ke(l%s%an Ne&a"aRe#-l%k In!(nes%a34
!en&an !%t#n#kkan ta-el !an &a$-a" !%-a2ah %n%.
No. Nama Ruangan
SKP 1% Kepatuhan pemasangangelang identitas pasien
1 ok 0
2 cp 8.79
3 bedah 8
4 ugd 0
5 hcu 0
6 kemala 0
7 bersalin 100
8 neonatus 100
9 anak 100% Total Kepatuhan pemasangan
gelang identitas pasien 39.59875
Hal %n% !%se-a-kan a!a 6 @t%&a "#an&an yan& -el#$ $en&%"%$ ke$-al%
k#es%(ne" ke t%$ k($%te KPRS ya%t# "#an& UGD/ H1U/ Ke$ala
seh%n&&a -el#$ $as#k !atanya.
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*. A!a&'sa P,!'!%kaa! Ku!'kas' *a!% ,3,k'3.
4 keat#han en&naan 1ABAK se-esa" 66/384 !en&an
!%t#n#kkan ta-el !an &a$-a" !%-a2ah %n%.
No. Nama Ruangan
SKP 2
% Kepatuhan penggunaan CABAK
1 ok 0
2 cp 4.3
3 bedah 4
4 ugd 0
5 hcu 0
6 kemala 0
7 bersalin 100
8 neonatus 63
9 anak 100% Total Kepatuhan penggunaan
CABAK 33.9125
Hal %n% !%se-a-kan a!a 6 @t%&a "#an&an yan& -el#$ $en&%"%$ ke$-al%
k#es%(ne" ke t%$ k($%te KPRS ya%t# "#an& UGD/ H1U/ Ke$ala
seh%n&&a -el#$ $as#k !atanya.
6. A!a&'sa P,!'!%kaa! K,aa!a! O-a *a!% (,#&u '5as(aa'.
4 Keat#han ket%a!aan eny%$anan K1l !%"#an&an se-esa" 8,, 4!en&an !%t#n#kkan ta-el !an &a$-a" !%-a2ah %n%.
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N. Naa Rua!%a!
SKP $
4 Keat#han ket%a!aan eny%$ananK1l !%"#an&an
8 (k 8,,
* ' 8,,
6 -e!ah 8,,
+ #&! 8,,
> h'# 8,,
5 ke$ala 8,,
7 -e"sal%n 8,,
9 ne(nat#s 8,,
3 anak 8,,
4 Ta& K,(au+a! k,'aaa! (,!*'(a!a!K& '#ua!%a! 8,,
Hal te"se-#t !%se-a-kan keat#han e"a2at !ala$ en&naan (-at
K1l yan& a"t%nya en&naan (-at K1l !%nakan ke as%en saat %t#
#&a.
+. A!a&'sa K,(as'a! ,(a &kas'7 ,(a (#s,u#7 ,(a (as',!
(,#as'
4 Keat#han keha!%"an (e"at(" !ala$ elaksanaan t%$e (#t se-esa"
8,, 4 !en&an !%t#n#kkan ta-el !an &a$-a" !%-a2ah %n%.
N. Naa Rua!%a!
SKP )
4 Keat#han keha!%"an (e"at("!ala$ elaksanaan t%$e (#t
8 OK 8,,
4 Ta& K,(au+a! k,+a'#a! (,#a# 8,,
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a&a (,&aksa!aa! ', u
Keat#han keha!%"an (e"at(" !ala$ elaksanaan t%$e (#t s#!ah
ses#a% "(se!#".
>. A!a&'sa P,!%u#a!%a! #'s'k '!3,ks' ,#ka' (,&a*a!a! k,s,+aa!.
4 keat#han '#'% tan&an se-esa" 68/+94 !en&an !%t#n#kkan ta-el
!an &a$-a" !%-a2ah %n%.
N. Naa Rua!%a!
SKP 8
4 K,(au+a! 9u9' a!%a!
8 (k 8,,
* ' +.6
6 -e!ah *>
+ #&! ,
> h'# ,
5 ke$ala ,
7 -e"sal%n +,
9 ne(nat#s 7>
3 anak 63.,5
4 Ta& K,(au+a! 9u9' a!%a! 68.+9++++++
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Hal %n% !%se-a-kan a!a 6 @t%&a "#an&an yan& -el#$ $en&%"%$ ke$-al%
k#es%(ne" ke t%$ k($%te KPRS ya%t# "#an& UGD/ H1U/ Ke$ala
seh%n&&a -el#$ $as#k !atanya.
5. A!a&'sa P,!%u#a!%a! #'s'k "au+. 4 T%!ak a!anya kea!%an as%en
at#h se-esa" 37/774 yan& !%t#n#kkan ta-el !an &a$-a" !%-a2ah %n%.
N. Naa Rua!%a!
SKP 6
4 T'ak aa!*a k,"a'a! (as',!"au+
8 (k 8,,
* ' 3,
6 -e!ah 8,,
+ #&! 8,,
> h'# 8,,
5 ke$ala 8,,
7 -e"sal%n 3,
9 ne(nat#s 8,,
3 anak 8,,
4 Ta& T'ak Aa!*a K,"a'a! (as',!Jau+ 37.77777779
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Te"!aat * kea!%an nya"%s 'e!e"a @KN1 ya%t# %ns%!en ase%n at#h !a"%
te$at t%!#" !% "#an& t"%-"ata !an %ns%!en as%en %n&san !% t(%let
-e"sal%n.
-. Ea&uas'
1. Ea&uas' K,,a(a! ',!'3'kas' (as',!.
4 Keat#han en&naan &elan& %!ent%tas as%en se-esa" 68/9+4.Hal %n% !%se-a-kan a!a 6 @t%&a "#an&an yan& -el#$ $en&%"%$ ke$-al%
k#es%(ne" ke t%$ k($%te KPRS ya%t# "#an& UGD/ H1U/ Ke$ala
seh%n&&a -el#$ $as#k !atanya. Unt#k -#lan e-"#a"%/ ket#a k($%te
KPRS yan& akt%= $as#k ket%&a "#an&an te"se-#t.2. Ea&uas' P,!'!%kaa! Ku!'kas' *a!% ,3,k'3.
4 Keat#han en&naan 1ABAK se-esa" 68/9+4. Hal %n%
!%se-a-kan a!a 6 @t%&a "#an&an yan& -el#$ $en&%"%$ ke$-al%
k#es%(ne" ke t%$ k($%te KPRS ya%t# "#an& UGD/ H1U/ Ke$ala
seh%n&&a -el#$ $as#k !atanya. Unt#k -#lan e-"#a"%/ ket#a k($%teKPRS yan& akt%= $as#k ket%&a "#an&an te"se-#t.
$. Ea&uas' P,!'!%kaa! K,aa!a! O-a *a!% (,#&u '5as(aa'.Keat#han en&naan (-at K1l s#!ah ses#a% "(se!#" ya%t#
!%en'e"kan !% #n%t =a"$as%. Teta% sta= =a"$as% -el#$ $e$%l%k% se"t%=%kat
elat%han en&en'e"an (-at K1l #nt#k $en&en'e"kan (-at K1l
seh%n&&a $en%n&katkan "es%k( medication error.). Ea&uas' K,(as'a! ,(a &kas'7 ,(a (#s,u#7 ,(a (as',!
(,#as'.
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4 Keat#han (e"at(" !ala$ elaksanaan t%$e (#t se-esa" 8,, 4.
Hal %n% $en#n#kkan ent%n&nya kee!#l%an (e"at(" !ala$ =ase t%$e
(#t.
8. Ea&uas' P,!%u#a!%a! #'s'k '!3,ks' ,#ka' (,&a*a!a! k,s,+aa!.
4 Keat#han '#'% tan&an se-esa" 68/+94. Hal %n% !%se-a-kan a!a 6
@t%&a "#an&an yan& -el#$ $en&%"%$ ke$-al% k#es%(ne" ke t%$ k($%te
KPRS ya%t# "#an& UGD/ H1U/ Ke$ala seh%n&&a -el#$ $as#k !atanya
!an #&a $as%h $%n%$ -#!aya '#'% tan&an te"#ta$a > $($ents !% RS.
BHAY. Wahy# T#t#k( B((ne&("( seh%n&&a e"l# !%lak#kan s(s%al%sas%
han! hy&%en%e !an #nt#k -#lan e-"#a"%/ ket#a k($%te KPRS yan& akt%=
$as#k ket%&a "#an&an @UGD/ H1U/ Ke$ala te"se-#t.6. Ea&uas' P,!%u#a!%a! #'s'k "au+. 4T%!ak a!anya kea!%an as%en
at#h se-esa" 37/774. Te"!aat * kea!%an nya"%s 'e!e"a @KN1 ya%t#!% "#an& t"%-"ata !an -e"sal%n. D% "#an& -e"sal%n/ kea!%an nya"%s 'e!e"a
@KN1 se-anyak 8 @sat# ("an& !% RS Bhayan&ka"a Wahy# T#t#k(
B((ne&("( !en&an n($e" kas#s ,*?,8?*,85. K"(n(l(&% Ins%!en0
as%en (st a"t#$ s(ntan ha"% 8 ke ka$a" $an!% $a# BAB ka"ena
-el#$ $akan !an -a!an le$as/ as%en %n&san !an ha$%" at#h !%
ka$a" $an!%/#nt#n&nya !%t(l(n& kel#a"&a as%en ka"ena kel#a"&a
as%en #&a %k#t $e$-ant# as%en saat as%en ke ka$a" $an!%.
D%"#an& T"%-"ata/ kea!%an nya"%s 'e!e"a @KN1 se-anyak 8 @sat# ("an&
!% RS Bhayan&ka"a Wahy# T#t#k( B((ne&("( !en&an n($e" kas#s
,8?,8?*,85. K"(n(l(&% Ins%!en0 as%en t%!ak a!a yan& $en#n&%/
as%en t#"#n !a"% te$at t%!#" !an $a# ke ka$a" $an!%/ -el#$ sa$a%
ke ka$a" $an!% as%en $en&($(l !an te"eleset ak%-at a%"
ken'%n&nya. Unt#k en%n&katan ke$a$#an e"a2at !ala$
$en"an&% "es%k( at#h/ e"l# a!anya s(s%al%sas% "es%k( at#h.
IV. PENUTUP
6. K,s'(u&a!
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Da"% La("an Anal%sa Dan E:al#as% Stan!a" Kesela$atan Pas%en R#$ah
Sak%t Bhayan&ka"a Tk.I; Wahy# T#t#k( B((ne&("( B#lan Jan#a"% *,85/
!%s%$#lkan -ah2a8. SKP 8)Ketetaan %!ent%=%kas% as%en. 4 Keat#han e$asan&an &elan&
%!ent%tas as%en se-esa" 63/>34.*. SKP *) Pen%n&katan K($#n%kas% yan& e=ekt%=. 4 Keat#han e"a2at
!ala$ en&naan 1ABAK se-esa" 66/3846. SKP 6:Pen%n&katan Kea$anan O-at yan& e"l# !%2asa!a%. 4 Keat#han
ket%a!aan eny%$anan K1l !% "#an&an se-esa" 8,,4.+. SKP +) Keast%an teat l(kas%/ teat "(se!#"/ teat as%en (e"as%. 4
Keat#han keha!%"an (e"at(" !ala$ elaksanaan t%$e (#t se-esa" 8,,
4.
>. SKP >) Pen"an&an "%s%k( %n=eks% te"ka%t elayanan kesehatan. 4Keat#han '#'% tan&an se-esa" 68/+9 4
5. SKP 5)Pen"an&an "%s%k( at#h. 4 Keat#han Pen"an&an "%s%k( at#h
se-esa" 37/774.
;. R,k,!as'
Setelah !%laksanakan La("an Anal%sa Dan E:al#as% Stan!a" Kesela$atan
Pas%en R#$ah Sak%t Bhayan&ka"a Tk.I; Wahy# T#t#k( B((ne&("( B#lan
Jan#a"% *,85/ !%sa"ankan 08. Pe"l#nya elat%han yan& te"at#" -a&% sta= RS yan& -e"#a elat%han KPRS
In)h(#se $a##n eC)h(#se t"a%n%n& yan& akan !%-%aya% sel#"#hnya (leh
"#$ah sak%t.*. Men!#k#n& !ala$ -ent#k enye!%aan =as%l%tas !an an&&a"an -%aya yan&
!%e"l#kan #nt#k $en&a!akan elat%han !an s(s%al%sas% se"ta e!#kas%
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yan& te"tat#" $en&ena%)atient safet'kea!a aa"an ka"ya2an "#$ah
sak%t.6. Men!("(n& sel#"#h e&a2a% RS #nt#k %k#t akt%= $ens#kseskan "(&"a$
)atient safet'.
De$%k%an La("an Anal%sa Dan E:al#as% Stan!a" Kesela$atan Pas%en
R#$ah Sak%t Bhayan&ka"a Tk.I; Wahy# T#t#k( B((ne&("( B#lan Jan#a"%
*,85 %n% !%-#at #nt#k !%a!%kan !asa" ata# e!($an !ala$ elaksanaan t#&as
seha"%)ha"% na $en%n&katkan $#t# elayanan kesehatan !% R#$ah Sak%t
Bhayan&ka"a Wahy# T#t#k( B((ne&("(.
B((ne&("(/ Jan#a"% *,85 KETUA KOMITE KPRS
BRE;MANA ANUGERAH P.
PENATA NIP 8395,*,8*,88,88,,8
POLRI DAERAH JAWA TIMUR
BIDANG KEDOKTERAN DAN KESEHATAN
RS BHAYANGKARA WAHYU TUTUKO BOJONEGORO
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DATAR ISI
I PENDAHULUAN 8
UMUM .. 8
MAKSUD DAN TUJUAN8
DASAR.*
A. RUANG LINGKUP.*
II TUGAS YANG DILAKSANAKAN..*
LAPORAN ANALISA DAN EVALUASI STANDAR KESELAMATAN PASIEN
RUMAH SAKIT BHAYANGKARA TK.IV WAHYU TUTUKO BOJONEGORO
BULAN JANUARI 2016
BOJONEGORO, FEBRUARI 2016
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III ANALISA DAN E;ALUASI....................................................................................*
I; PENUTUP.............................................................................................................3
KESIMPULAN......................................................................................................3
SARAN.................................................................................................................3