MEMBANGUN BUDAYA

MEMBANGUN BUDAYA
KESELAMATAN PASIEN
KESELAMATAN PASIEN
BUDI SAMPURNA
BUDI SAMPURNA
SISTEMATIKA
SISTEMATIKA

Pendahuluan
Pendahuluan

Pengertian Budaya Keselamatan pasien

Pengertian Budaya Keselamatan pasien

Manfaat Budaya Keselamatan pasien

Manfaat Budaya Keselamatan pasien

Survei Keselamatan Pasien

Survei Keselamatan Pasien
Medical services
Medical services
WHAT ARE THE HAZARDS
PROBABILITY, SEVERITY, AND EXPOSURE ?
LEVEL OF RISK ?
ACCEPTABLE ?
CAN IT BE ELIMINATED ?
CAN IT BE REDUCED ?
CANCEL THE MISSION
YES NO
ACCEPT THE RISK
ELIMINATE
REDUCED
SUDAHKAH SUATU PROSEDUR BETUL-BETUL AMAN?
ADAKAH POSSIBLE FAILURE MODE?
KENALILAH PENYEBAB KECELAKAAN, BAIK DARI
SISI FAKTOR MANUSIA MAUPUN FAKTOR SISTEM
MISHAP ANALYSIS
MISHAP ANALYSIS
MISHAP OCCURS
RISK UNACCEPTABLE RISK ACCEPTABLE
MANAGEMENT
FACTORS LTA
MISHAP
ACCEPTABLE
PREVENTION
METHODS
LTA
IMPLEMENTATION
PREVENTION
METHODS LTA
PREVENTION
POLICY LTA
IMPLEMENTATION
OF POLICY LTA
RISK ASSESSMENT
LTA
RISK PREVENTION
LTA
LTA = LESS THAN ADEQUATE
BUDAYA SAFETY
BUDAYA SAFETY
A safety culture is where staff within an
organisation have a constant and active
awareness of the potential for things to go
wrong. Both the staff and the organisation are
able to acknowledge mistakes, learn from them,
and take action to put things right.
Budaya keselamatan adalah dimana staf dalam suatu
organisasi memiliki kesadaran yg konstan dan aktif
tentang hal yg potensial menimbulkan kesalahan.
Baik staf maupun organisasi mampu membicarakan
kesalahan, belajar dari kesalahan tsb, dan mengambil
tindakan perbaikan
BUDAYA SAFETY
BUDAYA SAFETY
Being open and fair means sharing information
openly and freely, and fair treatment for staff
when an incident happens. This is vital for both
the safety of patients and the well-being of those
who provide their care.
Bersikap terbuka dan adil / jujur berarti membagi
informasi secara terbuka dan bebas, dan penanganan
adil bagi staf bila insiden terjadi.
Hal ini penting bagi keselamatan pasien dan
ketenangan bagi pemberi layanan
BUDAYA SAFETY
BUDAYA SAFETY
The systems approach to safety acknowledges
that the causes of a patient safety incident
cannot simply be linked to the actions of the
individual healthcare staff involved. All incidents
are also linked to the system in which the
individuals were working.
Pendekatan sistem pada keselamatan menerangkan
bahwa penyebab insiden keselamatan pasien tidak
dapat dihubungkan dengan sederhana ke staf yang
terlibat. Semua insiden berkaitan juga dengan sistem
tempat orang itu bekerja
BUDAYA SAFETY
BUDAYA SAFETY
Changing values, beliefs and attitudes is
not easy . Developing a safety culture in an
organisation needs strong leadership and
careful planning and monitoring.
Mengubah nilai-nilai, keyakinan, dan perilaku tidaklah
mudah. Pengembangan budaya keselamatan dalam
suatu organisasi memerlukan kepemimpinan yang kuat
dan perencanaan & pemantauan yang cermat
BUDAYA SAFETY
BUDAYA SAFETY
It is vital that not only clinical staff but all
those who work in organisations, as well
as patients and carers, ask themselves
how they can help to improve the safety of
patients.
Perubahan nilai, keyakinan dan perilaku tersebut
penting bukan hanya bagi staf, melainkan juga semua
orang yang bekerja di rumah sakit tersebut, serta
pasien dan keluarganya. Tanyakan apa yang bisa
mereka bantu untuk meningkatkan keselamatan pasien
KOMPONEN
KOMPONEN

1) acknowledgment of the high risk, error

1) acknowledgment of the high risk, error
-
-
prone nature of an organization's activities,
prone nature of an organization's activities,

2) blame
2) blame
-
-
free environment where
free environment where
individuals are able to report errors or close
individuals are able to report errors or close
calls without punishment,
calls without punishment,

3) expectation of collaboration across ranks

3) expectation of collaboration across ranks
to seek solutions to vulnerabilities, and
to seek solutions to vulnerabilities, and

4) willingness on the part of the

4) willingness on the part of the
organization to direct resources to address
organization to direct resources to address
safety concerns.
safety concerns.
Penjelasan / pemahaman tentang aktivitas
organisasi yang bersifat risiko tinggi dan rentan
kesalahan
Lingkungan yang bebas-menyalahkan, sehingga
orang dapat melapor kesalahan tanpa
penghukuman
Harapan kerjasama lintas tingkatan untuk mencari
solusi atas vulnerabilitas
Kemauan organisasi untuk mengarahkan sumber
daya untuk kepentingan keselamatan
AHRQ
Components of a Culture of Safety
Commitment to safety articulated at the highest levels of the
organization and translated into shared values, beliefs, and
behavioral norms at all levels.
Necessary resources, incentives, and rewards provided by the
organization to allow this commitment to occur.
Safety is valued as the primary priority, even at the expense of
production or efficiency ; personnel are rewarded for erring on
the side of safety even if they turn out to be wrong.
Communication between workers and across organizational levels
is frequent and candid.
Unsafe acts are rare despite high levels of production.
There is an openness about errors and problems; they are reported
when they do occur.
Organizational learning is valued; the response to a problem
focuses on improving system performance rather than on individual
blame.
Source: Singer SJ, Gaba DM, Geppert JJ, et al. The culture of safety: results of an organization-wide
survey in 15 California hospitals. Qual Saf Health Care 2003 Apr;12(2):112-8.
Reproduced with permission from the BMJ Publishing Group.
BLAMING
BLAMING
vs
vs
SAFETY
SAFETY

BLAMING:
BLAMING:

ANALISIS BERAKHIR PADA HUMAN FACTORS
ANALISIS BERAKHIR PADA HUMAN FACTORS

TINDAKAN: MENYALAHKAN DAN MENGHUKUM
TINDAKAN: MENYALAHKAN DAN MENGHUKUM
(LESS) REWARD AND (MORE) PUNISHMENT
(LESS) REWARD AND (MORE) PUNISHMENT

SIKAP: SEMBUNYIKAN KESALAHAN
SIKAP: SEMBUNYIKAN KESALAHAN

SAFETY:
SAFETY:

REPORTING, ANALYSIS, LEARNING,
REPORTING, ANALYSIS, LEARNING,

(MORE) REWARD AND (LESS) PUNISHMENT
(MORE) REWARD AND (LESS) PUNISHMENT

TINDAKAN: CARI UPAYA PENCEGAHAN
TINDAKAN: CARI UPAYA PENCEGAHAN

SIKAP: BERLOMBA BERBUAT BAIK DAN
SIKAP: BERLOMBA BERBUAT BAIK DAN
MENCEGAH YG BURUK (BUDAYA BELAJAR)
MENCEGAH YG BURUK (BUDAYA BELAJAR)
BLAMING ?
BLAMING ?
SUPPORTING?
SUPPORTING?
SIKAP RUMAH SAKIT
SIKAP RUMAH SAKIT
Pastikan RS memiliki kebijakan yg
menjabarkan apa yg harus dilakukan staf
segera setelah terjadi insiden, bagaimana
langkah pengumpulan fakta harus dilakukan
& dukungan apa yang harus diberikan
kepada staf, pasien - keluarga
Pastikan RS memiliki kebijakan yg
menjabarkan peran & akuntabilitas individual
bilamana ada insiden
Tumbuhkan budaya pelaporan & belajar dari
insiden yang terjadi di RS.
Lakukan asesmen dengan menggunakan
survei penilaian KP
KKP RS
SIKAP STAF DALAM TIM
SIKAP STAF DALAM TIM
Pastikan rekan sekerja anda merasa
mampu untuk berbicara mengenai
kepedulian mereka & berani melaporkan
bilamana ada insiden
Demonstrasikan kepada tim anda ukuran
yang dipakai di RS anda utk memastikan
semua laporan dibuat secara terbuka &
terjadi proses pembelajaran serta
pelaksanaan tindakan / solusi yg tepat
KKP RS
TERBUKA DAN JUJUR
TERBUKA DAN JUJUR
staff are open about incidents they have been
involved in;
staff and organisations are accountable for their
actions;
staff feel able to talk to their colleagues and
superiors about any incident;
organisations are open with patients, the public
and staff when things have gone wrong, and
explain what lessons will be learned;
staff are treated fairly and supported when an
incident happens.
NHS
Being open and fair does not
mean an absence of
accountability.
Accountability for patient safety means being open
with patients, explaining the actions taken and
providing assurance
that lessons will be learned.
NHS
TERBUKA DAN JUJUR
TERBUKA DAN JUJUR
SINGKIRKAN MITOS
SINGKIRKAN MITOS
-
-
MITOS:
MITOS:
the perfection myth:
bila orang bekerja keras maka mereka tidak
akan membuat errors
the punishment myth:
bila kita menghukum orang yang melakukan
errors maka akan semakin sedikit pembuat
errors, atau bahwa tindakan pendisiplinan
dapat memperbaiki melalui channelling atau
meningkatkan motivasi.
NHS
Penanganan Insiden
Penanganan Insiden

Staff harus sama persepsinya tentang

Staff harus sama persepsinya tentang
insiden
insiden

Staff harus tahu apa yang harus dilakukan

Staff harus tahu apa yang harus dilakukan
bila menemui insiden: mencatat, melapor,
bila menemui insiden: mencatat, melapor,
dianalisis, memperoleh feed
dianalisis, memperoleh feed
-
-
back, belajar
back, belajar
dan mencegah pengulangan
dan mencegah pengulangan

Staff harus akuntabel dan tahu bagaimana

Staff harus akuntabel dan tahu bagaimana
pendekatan sistem dan personil
pendekatan sistem dan personil
RESOLUTION OF ERROR
RESOLUTION OF ERROR
NEGLECT / USED WRONG PROCEDURE
DID NOT KNOW
CORRECT
PROCEDURE
KNEW CORRECT
PROCEDURE
LACKED
EXPERIENCE
LACKED
INFORMATION
LACKED TRAINING
OR PRACTICE
LACKED
TRAINING
DELIBERATE,
INTENTIONAL
TOLERATED
PRESSURES
LACKED
DISCIPLINE
PUNISHMENT
NEVER KNEW FORGOT
MANAGEMENT ACTION TO CORRECT THE SYSTEM
MENGAPA BUDAYA SAFETY?
MENGAPA BUDAYA SAFETY?

Bukti di industri lain menunjukkan bahwa

Bukti di industri lain menunjukkan bahwa
budaya organisasi yang berorientasi ke
budaya organisasi yang berorientasi ke
keselamatan dan sikap karyawan yang
keselamatan dan sikap karyawan yang
berani bicara tentang terjadinya kesalahan
berani bicara tentang terjadinya kesalahan
telah meningkatkan keselamatan
telah meningkatkan keselamatan

Di Rumah Sakit Wimmera

Di Rumah Sakit Wimmera
-
-
Australia:
Australia:

Penurunan Adverse Events
Penurunan Adverse Events

Pd pasien rawat inap : 1,35%
Pd pasien rawat inap : 1,35%
-
-
0,74%
0,74%

Pd pasien IGD : 3,26%
Pd pasien IGD : 3,26%
-
-
0,48%
0,48%
MANFAAT BUDAYA SAFETY
MANFAAT BUDAYA SAFETY
a potential reduction in the recurrence and
in the severity of patient safety incidents
through increased reporting and
organisational learning;
Potensi mengurangi angka kejadian dan
keparahan kejadian patient safety melalui
peningkatan pelaporan dan pembelajaran
organisasi
MANFAAT BUDAYA SAFETY
MANFAAT BUDAYA SAFETY
a reduction in the physical and
psychological harm patients can suffer
because people are more aware of patient
safety concepts, are working to prevent
errors and are speaking up when things go
wrong;
Pengurangan derita fisik dan psikologis pasien,
karena orang makin sadar tentang konsep
patient safety akan bekerja mencegah
kesalahan dan berbicara bila terjadi kesalahan
MANFAAT BUDAYA SAFETY
MANFAAT BUDAYA SAFETY
a lower number of staff suffering from
distress, guilt, shame, loss of confidence
and loss of morale because fewer
incidents are occurring;
Penurunan jumlah staf yang menderita
tertekan, merasa bersalah, malu, kehilangan
percaya diri, dan kehilangan keberanian
mental, karena berkurangnya insiden yang
terjadi
MANFAAT BUDAYA SAFETY
MANFAAT BUDAYA SAFETY
an improvement in waiting times for
treatment through a higher turnover of
patients. This is because patients who
experience a safety incident require, on
average, an extra seven to eight days in
hospital over and above the time their
treatment would normally require ;
Peningkatan turnover pasien, mengingat
pasien yg terkena insiden umumnya
membutuhkan perawatan 7-8 hari lebih dari
masa rawat normal
MANFAAT BUDAYA SAFETY
MANFAAT BUDAYA SAFETY
a reduction in the costs incurred for
treatment and extra therapy;
a reduction in resources required for
managing complaints and claims;
Pengurangan biaya untuk pengobatan /
penatalaksanaan ekstra akibat insiden
Pengurangan kebutuhan sumber daya untuk
menangani komplain dan klaim
MANFAAT BUDAYA SAFETY
MANFAAT BUDAYA SAFETY
a decrease in wider financial and social
costs incurred through patient safety
incidents including lost work time and
disability benefits.
Penurunan biaya finansial dan sosial yang
diperlukan untuk menangani insiden patient
safety, termasuk kehilangan jam kerja dan
pembayaran kecacatan
BAGAIMANA MEMULAI
BAGAIMANA MEMULAI
PENERAPAN BUDAYA
PENERAPAN BUDAYA
KESELAMATAN PASIEN?
KESELAMATAN PASIEN?
MULAILAH DENGAN SURVEI
MULAILAH DENGAN SURVEI
TENTANG ISU
TENTANG ISU
:
:
Bagaimana kemampuan managemen
senior melihat ke depan dan
berkomitmen ke arah keselamatan
Bagaimana komunikasi antara staf
dengan manager
TENTANG ISU:
Bagaimana sikap dan perilaku dalam
melaporkan suatu kejadian, blaming dan
penghukumannya
Bagaimana faktor-faktor dalam lingkungan
kerja mempengaruhi kinerja, seperti
kelelahan, pemecahan perhatian, desain
peralatan dan ketersediaan/kesiapan alat.
TOOLS UNTUK SURVEI
TOOLS UNTUK SURVEI

TYPOLOGY:
TYPOLOGY:
Checklist for Assessing Institutional Resilience (CAIR )
Manchester Patient Safety Assessment Tool20
(MaPSaT)
Advancing Health in America (AHA) and Veterans
Health Association (VHA): Strategies for Leadership.
An Organisational Approach to Patient Safety
DIMENSIONAL:
Safety Attitudes Questionnaire (SAQ)
Stanford Patient Safety Centre of Inquiry Culture
Survey
contoh
I. Background Variables
I. Background Variables
A.
A.
What is your primary work area or unit in this hospital?
What is your primary work area or unit in this hospital?
H1.
H1.
How long have you worked in this
How long have you worked in this
hospital?
hospital?
H2.
H2.
How long have you worked in your current hospital
How long have you worked in your current hospital
work area/unit?
work area/unit?
H3.
H3.
Typically, how many
Typically, how many
hours per week
hours per week
do you work in
do you work in
this hospital?
this hospital?
H4.
H4.
What is your staff
What is your staff
position
position
in this hospital?
in this hospital?
H5.
H5.
In your staff position, do you typically have direct
In your staff position, do you typically have direct
interaction or
interaction or
contact with patients
contact with patients
?
?
H6.
H6.
How long have you worked in your current specialty
How long have you worked in your current specialty
or profession?
or profession?
contoh
II. Outcome measures
II. Outcome measures
contoh

Frequency of Event Reporting

Frequency of Event Reporting

Overall Perceptions of Safety

Overall Perceptions of Safety

Patient Safety Grade

Patient Safety Grade

Number of Events Reported

Number of Events Reported
contoh
Overall Perceptions of Safety:
Overall Perceptions of Safety:

A15.
A15.
Patient safety is never sacrificed to get
Patient safety is never sacrificed to get
more
more
work done.
work done.

A18.
A18.
Our procedures and systems are good
Our procedures and systems are good
at preventing errors from happening.
at preventing errors from happening.

A10r.
A10r.
It is just by chance that more serious
It is just by chance that more serious
mistakes don
mistakes don

t happen around here.

t happen around here.
(reverse worded)
(reverse worded)

A17r.
A17r.
We have patient safety problems in this
We have patient safety problems in this
unit
unit
(reverse worded)
(reverse worded)
Reliability of this dimension Reliability of this dimension Cronbach Cronbach s s alpha (4 items) = .74 alpha (4 items) = .74
Keselamatan pasien tidak pernah dikorbankan untuk
memperbanyak pekerjaan yang bisa dikerjakan
Prosedur dan sistem kita adalah bagus dalam mencegah
terjadinya kesalahan
Hanyalah suatu kebetulan bahwa kesalahan yang lebih
serius tidak terjadi disini (neg)
Kita memiliki masalah keselamatan pasien di unit ini (neg)
III.
III.
Safety Culture Dimensions
Safety Culture Dimensions
(Unit level)
(Unit level)
contoh

Supervisor/manager expectations & actions
Supervisor/manager expectations & actions
promoting safety
promoting safety

Organizational Learning
Organizational Learning

Continuous
Continuous
improvement
improvement

Teamwork Within Hospital Units
Teamwork Within Hospital Units

Communication Openness
Communication Openness

Feedback and Communication About Error
Feedback and Communication About Error

Nonpunitive
Nonpunitive
Response To Error
Response To Error

Staffing
Staffing

Hospital Management Support for Patient
Hospital Management Support for Patient
Safety
Safety
Harapan dan tindakan supervisor dan manajer dalam
mempromosikan keselamatan
Pembelajaran organisasi perbaikan kontinyu
Kerjasama tim di RS
Keterbukaan dalam berkomunikasi
Umpan balik dan komunikasi tentang Kesalahan
Tanggapan yang tidak menghukum terhadap kesalahan
Staff
Manajemen RS mendukung Keselamatan Pasien
contoh
Supervisor/manager expectations & actions
Supervisor/manager expectations & actions
promoting safety
promoting safety
B1.
B1.
My supervisor/manager says a good word when
My supervisor/manager says a good word when
he/she sees a job done according to established
he/she sees a job done according to established
patient safety procedures.
patient safety procedures.
B2.
B2.
My supervisor/manager seriously considers staff
My supervisor/manager seriously considers staff
suggestions for improving patient safety.
suggestions for improving patient safety.
B3r.
B3r.
Whenever pressure builds up, my supervisor/manager
Whenever pressure builds up, my supervisor/manager
wants us to work faster, even if it means taking
wants us to work faster, even if it means taking
shortcuts. (reverse worded)
shortcuts. (reverse worded)
B4r.
B4r.
My supervisor/manager overlooks patient safety
My supervisor/manager overlooks patient safety
problems that happen over and over. (reverse
problems that happen over and over. (reverse
worded)
worded)
Reliability of this dimension Reliability of this dimension Cronbach Cronbach s s alpha (4 items) = .75 alpha (4 items) = .75
Supervisor / Manajer:
Memuji bila staf melakukan prosedur PS
Mempertimbangkan usulan staf untuk peningkatan PS
Memerintahkan percepatan kerja dengan melakukan jalan
pintas (neg)
Tidak memperhatikan masalah PS yg sudah terjadi
berulang (neg)
contoh
Teamwork Within Hospital Units
Teamwork Within Hospital Units
A1.
A1.
People support one another in this unit.
People support one another in this unit.
A3.
A3.
When a lot of work needs to be done quickly,
When a lot of work needs to be done quickly,
we work together as a team to get the work
we work together as a team to get the work
done.
done.
A4.
A4.
In this unit, people treat each other with
In this unit, people treat each other with
respect.
respect.
A11.
A11.
When one area in this unit gets really busy,
When one area in this unit gets really busy,
others help out.
others help out.
Reliability of this dimension Reliability of this dimension Cronbach Cronbach s s alpha (4 items) = .83 alpha (4 items) = .83
Orang saling membantu di unit ini
Bila terdapat pekerjaan banyak yg membutuhkan
diselesaikan secepatnya, kita bekerja bersama dalam satu
tim untuk menyelesaikannya
Dalam unit ini orang memperlakukan orang lain dengan
hormat
Bila salah satu area di unit ini sibuk, maka yang lain akan
membantunya
IV.
IV.
Safety Culture Dimensions
Safety Culture Dimensions
(Hospital
(Hospital
-
-
wide)
wide)
contoh

Teamwork Across Hospital Units

Teamwork Across Hospital Units

Hospital Handoffs & Transitions

Hospital Handoffs & Transitions
contoh
Teamwork Across Hospital Units
Teamwork Across Hospital Units
F4.
F4.
There is good cooperation among hospital
There is good cooperation among hospital
units that need to work together.
units that need to work together.
F10.
F10.
Hospital units work well together to provide
Hospital units work well together to provide
the best care for patients.
the best care for patients.
F2r.
F2r.
Hospital units do not coordinate well with
Hospital units do not coordinate well with
each other. (reverse worded)
each other. (reverse worded)
F6r.
F6r.
It is often unpleasant to work with staff from
It is often unpleasant to work with staff from
other hospital units. (reverse worded)
other hospital units. (reverse worded)
Reliability of this dimension Reliability of this dimension Cronbach Cronbach s s alpha (4 items) = .8 alpha (4 items) = .8
Terdapat kerjasama yg baik antar unit yg
harus bekerjasama
Unit-unit bekerja bersama untuk memberi
layanan terbaik kepada pasien
Unit-unit tidak bekerjasama satu sama lain
(neg)
Sangat tidak menyebangkan bekerja
dengan staf dari unit lain (neg)
MANFAAT SURVEI
MANFAAT SURVEI

Suatu organisasi perlu mengetahui

Suatu organisasi perlu mengetahui
budayanya yg sekarang sebelum bisa
budayanya yg sekarang sebelum bisa
mengubah budaya tersebut
mengubah budaya tersebut

Mengubah sikap dan perilaku itu sulit dan

Mengubah sikap dan perilaku itu sulit dan
lama, perlu pemahaman tentang
lama, perlu pemahaman tentang
keselamatan pasien dan pendekatan
keselamatan pasien dan pendekatan
sistem pada
sistem pada

errors
errors

dan
dan

incidents
incidents

Leadership penting dalam membentuk

Leadership penting dalam membentuk

value
value

dan
dan

belief
belief

dalam budaya
dalam budaya
LEVEL OF MATURITY WITH RESPECT
LEVEL OF MATURITY WITH RESPECT
TO A SAFETY CULTURE
TO A SAFETY CULTURE
Risk
management
Is an integral
Part of
Everything
That we do
Risk
management
Is an integral
Part of
Everything
That we do
We are
always
On alert for
Risks that
Might
emerge
We are We are
always always
On alert for On alert for
Risks that Risks that
Might Might
emerge emerge
We have
systems in
Place to
Manage all
Like risks
We have
systems in
Place to
Manage all
Like risks
We do
Something
when we
Have an
incident
Why waste
our time
On safety?
Why waste Why waste
our time our time
On safety? On safety?
SELANJUTNYA
SELANJUTNYA
BAGAIMANA?
BAGAIMANA?
Langkah
Langkah
-
-
langkah
langkah
1. Assess the culture of safety.
2. Provide science-of-safety education.
3. Identify safety concerns.
4. Establish senior leader partnerships with
units.
5. Learn from one defect per month.
6. Re-assess (re-measure) the culture of
safety.
Membangun budaya adalah suatu siklus yg tak henti-henti
ACTION RECOMMENDATIONS
Seek leadership support for the creation of a
culture of safety throughout the organization.
Support can be gained by providing data
demonstrating that communication problems are
major causes of medical errors and information on
how teamwork failures lead to malpractice claims
and by sharing success stories of facilities that
have affected patient safety by improving safety
culture.
ACTION RECOMMENDATIONS
Partner with clinicians and managers in conducting
an assessment of the existing safety climate in the
organization. Appoint a project team, accountable
to a senior executive, to carry out the assessment
using surveys, interviews, or other techniques.
Based on survey findings, formulate and execute
an action plan to improve the culture of safety.
Establish realistic measures to gauge the
effectiveness of action plans.
ACTION RECOMMENDATIONS
Provide safety science education to
frontline staff, managers, and physicians.
Include teamwork training and education
in communication techniques.
Incorporate safety culture initiatives into
the overall organizational patient safety
plan. Ensure that patient safety initiatives,
action plans, and results of interventions
to improve safety are periodically reported
to the board of directors.
ACTION RECOMMENDATIONS
Establish a nonpunitive system for reporting
errors, events, and near misses. Consider
implementing a reward-based reporting system,
and ensure timely feedback to staff on how
reports are used to improve patient safety.
Ensure that disclosure policies are in keeping
with current regulations and standards. Work
toward using disclosure with apology as a claim-
avoidance strategy.
ACTION RECOMMENDATIONS
Share information on improvements and
successes based on safety culture
changes to maintain enthusiasm for
participation and support. Communicate
plans to address areas still in need of
improvement and other opportunities to
enhance patient safety.
Pengalaman
Pengalaman
VHA
VHA

The Veterans Health Administration (VHA) has
The Veterans Health Administration (VHA) has
implemented a multifaceted safety initiative,
implemented a multifaceted safety initiative,
which was designed to build a culture of safety
which was designed to build a culture of safety
and address system failures.
and address system failures.

The approach consists of 4 major elements:
The approach consists of 4 major elements:

1) partnering with other safety
1) partnering with other safety
-
-
related organizations
related organizations
and affiliates to demonstrate a public commitment by
and affiliates to demonstrate a public commitment by
leadership,
leadership,

2) establishing centers to direct safety efforts,
2) establishing centers to direct safety efforts,

3) improving reporting systems, and
3) improving reporting systems, and

4) providing incentives to health care team members
4) providing incentives to health care team members
and division leaders. These tactics are detailed below
and division leaders. These tactics are detailed below
Pengalaman
Pengalaman
SMUH
SMUH
South Manchester University Hospital
South Manchester University Hospital

Membangun sistem pelaporan insiden

Membangun sistem pelaporan insiden
yang berbasis web bagi ujung tombak
yang berbasis web bagi ujung tombak

Bila laporan dimasukkan, sistem langsung

Bila laporan dimasukkan, sistem langsung
mengirim email ke Manajemen
mengirim email ke Manajemen

RS merawat inap 69.000 pasien/tahun

RS merawat inap 69.000 pasien/tahun

Expected AE: 7.000 / tahun

Expected AE: 7.000 / tahun

Setelah 3 tahun sistem dibangun, laporan

Setelah 3 tahun sistem dibangun, laporan
sudah mencapai 4.500 / tahun
sudah mencapai 4.500 / tahun

3
3
-
-
7% anonim, dirangsang utk pakai nama
7% anonim, dirangsang utk pakai nama
Pengalaman
Pengalaman
SMUH
SMUH
South Manchester University Hospital
South Manchester University Hospital

Penjelasan tentang hubungan antara

Penjelasan tentang hubungan antara
Pelaporan dengan Pendisiplinan
Pelaporan dengan Pendisiplinan

Penjelasan tentang hubungan antara

Penjelasan tentang hubungan antara
Pelaporan dan pembelajaran
Pelaporan dan pembelajaran

Pelatihan dilakukan di tempat

Pelatihan dilakukan di tempat

Informasi dalam web: clinical risk, medical

Informasi dalam web: clinical risk, medical
alert, archived safety materials, patient
alert, archived safety materials, patient
safety newsletter
safety newsletter
OSF St. Joseph Medical Center,
OSF St. Joseph Medical Center,
in Bloomington, Ill.
in Bloomington, Ill.

Membolehkan juga pelaporan bersifat

Membolehkan juga pelaporan bersifat
informal oleh staf keperawatan, ahli
informal oleh staf keperawatan, ahli
farmasi, laboratorium dll, melalui:
farmasi, laboratorium dll, melalui:

Briefing saat pergantian shift jaga
Briefing saat pergantian shift jaga

Ronde rutin oleh manajemen
Ronde rutin oleh manajemen

Telepon hotline
Telepon hotline
Krause et al
Krause et al
Di luar bidang kedokteran:
Di luar bidang kedokteran:

safety assessments,
safety assessments,

steering committee formation,

steering committee formation,

development of checklists of well

development of checklists of well
-
-
specified
specified
critical behaviors related to safety
critical behaviors related to safety

observer training regarding the critical

observer training regarding the critical
behaviors,
behaviors,

observation and feedback

observation and feedback
FAKTA
FAKTA

Dengan sistem patient Safety, Sentara Norfolk General
Dengan sistem patient Safety, Sentara Norfolk General
Hospital: 84 % pengurangan Pneumonia yg berkaitan dg
Hospital: 84 % pengurangan Pneumonia yg berkaitan dg
ventilator dari 2001 s/d Juni 2004
ventilator dari 2001 s/d Juni 2004

Dengan Tim Tanggap Cepat di Missouri Baptist Medical
Dengan Tim Tanggap Cepat di Missouri Baptist Medical
Center telah menurunkan 60 % penurunan panggilan
Center telah menurunkan 60 % penurunan panggilan
darurat henti nafas dan krisis serupa dan penurunan
darurat henti nafas dan krisis serupa dan penurunan
15% henti jantung.
15% henti jantung.

Johns Hopkins Hospital mengalami peningkatan 49
Johns Hopkins Hospital mengalami peningkatan 49
-
-
91
91
% proporsi pelaporan staf ICU tentang iklim safety dan
% proporsi pelaporan staf ICU tentang iklim safety dan
menghilangkan kasus infeksi pembuluh darah akibat
menghilangkan kasus infeksi pembuluh darah akibat
kateterisasi, mencegah 8 kematian dan berhemat $2 juta
kateterisasi, mencegah 8 kematian dan berhemat $2 juta
pertahun.
pertahun.

Kasus adverse drug events menurun 91 percent di OSF
Kasus adverse drug events menurun 91 percent di OSF
St. Joseph Medical Center.
St. Joseph Medical Center.
KATA AKHIR
KATA AKHIR

Keselamatan Pasien di Rumah Sakit

Keselamatan Pasien di Rumah Sakit
hanya dapat dicapai dengan membangun
hanya dapat dicapai dengan membangun
budaya yang berorientasikan kepada
budaya yang berorientasikan kepada
keselamatan pasien
keselamatan pasien

Budaya keselamatan pasien harus

Budaya keselamatan pasien harus
dipahami, dihayati dan diamalkan oleh
dipahami, dihayati dan diamalkan oleh
seluruh unsur rumah sakit
seluruh unsur rumah sakit

Peran pimpinan, baik formil maupun non

Peran pimpinan, baik formil maupun non
formil diperlukan dalam membentuk
formil diperlukan dalam membentuk

nilai
nilai

dan memberi teladan.

dan memberi teladan.