bs medical audit 2006 - 8

7/26/2019 Bs Medical Audit 2006 - 8

http://slidepdf.com/reader/full/bs-medical-audit-2006-8 1/42

BUDI SAMPURNABUDI SAMPURNA



Over useOver use pelayananpelayanan

CABGCABG tidak sesuai prosedur: tidak sesuai prosedur:14 % di US, 21% di Inris, !% di14 % di US, 21% di Inris, !% di

"anada"anada

URTIURTI , #$&$ % pe'(erian resep, #$&$ % pe'(erian resep

anti(ioti) tidak sesuai untuk in*eksianti(ioti) tidak sesuai untuk in*eksi

+irus+irus

NSAIDSNSAIDS : 42 % 'endapatkan resep: 42 % 'endapatkan resep

yan tidak diperlukanyan tidak diperlukan



under useunder use pelayananpelayanan

anya &- % anak yan 'endapatanya &- % anak yan 'endapat

i'unisasi lenkap dani'unisasi lenkap dan

.anya 1- % pasien DM yan.anya 1- % pasien DM yandiperiksadiperiksa HbA1C.HbA1C.

PasienPasien CADCAD yan perlu dilakukanyan perlu dilakukan

inter+ensi .anya 42 -1 % yaninter+ensi .anya 42 -1 % yan

dilaksanakandilaksanakan



Ad+erse e+entsAd+erse e+ents

Ne/ 0orkNe/ 0ork 1!41!4 #$1!3#$1!3 # %# %

Uta."oloradoUta."olorado 1!!21!!2 143-3143-3 #2 %#2 %

Australia 5A"S6Australia 5A"S6 1!!21!!2 141&!141&! 1-- %1-- %

U7 U7 1!!!1!!! 1$141$14 11& %11& %

Den'arkDen'ark 1!!1!! 1$!&1$!& !$ %!$ %

Ne/ 8ealandNe/ 8ealand 1!!1!! -3&!-3&! 12! %12! %

"anada"anada 2$$12$$1 #&2$#&2$ &3 %&3 %

IndonesiaIndonesia 999999 999999

Iwan Dwiprahasto, 2005



77SA;ASA;AANAN PN<=BA>ANPN<=BA>AN

DI AS:DI AS: 7SA;AAN PMBRIAN =BA> DI 2 RUM7I>7SA;AAN PMBRIAN =BA> DI 2 RUM7I>

DI AS: 3-% DAN #4% BA>S, 1!!36DI AS: 3-% DAN #4% BA>S, 1!!36 7SA;AAN BDA : 1:3$ PASIN RA?A>7SA;AAN BDA : 1:3$ PASIN RA?A>

<A?AND, 1!!!6<A?AND, 1!!!6

DI IND=NSIA:DI IND=NSIA:

I/an D/ipra.asto MMedS), P.D di @oa:I/an D/ipra.asto MMedS), P.D di @oa: MDI"A>I=N RR=R DI I"U MN"APAI !-%MDI"A>I=N RR=R DI I"U MN"APAI !-%

>A7 SSUAI INDI7ASI, >A7 SSUAI D=SIS,>A7 SSUAI INDI7ASI, >A7 SSUAI D=SIS,P=;IARMA7A >A7 ;=<IS, D;;6P=;IARMA7A >A7 ;=<IS, D;;6

MDI"A>I=N RR=R DI PUS7SMAS: $AN %MDI"A>I=N RR=R DI PUS7SMAS: $AN %

MUDAMUDAAN BU7AN "RMIN 7D=7>RAN



MNU@U 7D=7>RAN 0<MNU@U 7D=7>RAN 0<

AMANAMAN

PRUBAANPARADI<MA

PRUBAANSIS>M

PRUBAAN SI7APDAN PRI;A7U



PA>IN> SA>0PA>IN> SA>0

7S;AMA>AN PASIN RS ADA;A PR=SS7S;AMA>AN PASIN RS ADA;A PR=SS

DA;AM SUA>U RS 0< MMBRI7ANDA;AM SUA>U RS 0< MMBRI7AN

P;A0ANAN PASIN 0AN< ;BI AMANP;A0ANAN PASIN 0AN< ;BI AMAN

M;IPU>I UPA0A: ASSMN RISI7=,M;IPU>I UPA0A: ASSMN RISI7=,IDN>II7ASI DAN MANA@MN RISI7= >DIDN>II7ASI DAN MANA@MN RISI7= >D

PASIN, P;AP=RAN DAN ANA;ISISPASIN, P;AP=RAN DAN ANA;ISIS

INSIDN, 7MAMPUAN UN>U7 B;A@ARINSIDN, 7MAMPUAN UN>U7 B;A@AR

DAN MNINDA7;AN@U>I INSIDN DANDAN MNINDA7;AN@U>I INSIDN DANMNRAP7AN S=;USI UN>U7MNRAP7AN S=;USI UN>U7

MN<URAN<I SR>A MMINIMA;ISASIMN<URAN<I SR>A MMINIMA;ISASI

>IMBU;N0A RISI7= >IMBU;N0A RISI7=KKP RS



<==D <=CRNAN"<==D <=CRNAN"

a framework trou! w"#a framework trou! w"#

ea$t #are or!an"%at"ons areea$t #are or!an"%at"ons are

a##ountab$e for #ont"nuous$&a##ountab$e for #ont"nuous$&"m'rov"n! te (ua$"t& of te"r"m'rov"n! te (ua$"t& of te"r

serv"#es and safe!uard"n! "!serv"#es and safe!uard"n! "!

standards of #are b& #reat"n! anstandards of #are b& #reat"n! anenv"ronment "n w"# e)#e$$en#eenv"ronment "n w"# e)#e$$en#e

"n #$"n"#a$ #are w"$$ *our"s"n #$"n"#a$ #are w"$$ *our"s

NS



&& PI;ARPI;AR

<==D ";INI"A;<==D ";INI"A;

<=CRNAN"<=CRNAN"#$"n"#a$ e+e#t"veness ,#$"n"#a$ aud"t-#$"n"#a$ e+e#t"veness ,#$"n"#a$ aud"t-r"sk mana!ement e+e#t"venessr"sk mana!ement e+e#t"veness

'at"ent e)'er"en#e 'at"ent e)'er"en#e#ommun"#at"on e+e#t"veness#ommun"#at"on e+e#t"venessedu#at"on and $"fe/$on! $earn"n!edu#at"on and $"fe/$on! $earn"n!

resear# and $earn"n! e+e#t"venessresear# and $earn"n! e+e#t"venessresour#e e+e#t"veness ,#$"n"#a$resour#e e+e#t"veness ,#$"n"#a$

"nformat"on and sta0n!- and"nformat"on and sta0n!- and

strate!"# e+e#t"venessstrate!"# e+e#t"veness NS



MANA@MN RISI7=MANA@MN RISI7=

MANA@MN RISI7= ADA;A A7>ICI>ASMANA@MN RISI7= ADA;A A7>ICI>AS

7;INI7 DAN ADMINIS>RA>I 0AN<7;INI7 DAN ADMINIS>RA>I 0AN<

DI;A7U7AN =; RUMA SA7I> "=6DI;A7U7AN =; RUMA SA7I> "=6

UN>U7 M;A7U7AN IDN>II7ASI,UN>U7 M;A7U7AN IDN>II7ASI,

CA;UASI DAN PN<URAN<AN RISI7=CA;UASI DAN PN<URAN<AN RISI7=

>R@ADIN0A "DRA A>AU 7RU<IAN >R@ADIN0A "DRA A>AU 7RU<IAN

PADA PASIN, PRS=NI;, PN<UN@UN<PADA PASIN, PRS=NI;, PN<UN@UN<DAN INS>I>USI RUMA SA7I>DAN INS>I>USI RUMA SA7I>

THE JOINT COMMISSION ON ACCREDITATION OF HEALTHCARE ORGANIZATIONS



AUDI>AUDI>

AUDI> 7UAN<AN:AUDI> 7UAN<AN: untuk 'e'(uktikan (a./a 'etode akuntasiuntuk 'e'(uktikan (a./a 'etode akuntasi

sesuatu oranisasi 'e'(eri representasi yansesuatu oranisasi 'e'(eri representasi yan/aar dari status keuanan/aar dari status keuanan

AUDI> MU>U:AUDI> MU>U: penilaian penendalian se)ara independen,penilaian penendalian se)ara independen,

siste'atis, terstruktur yan 'e'penaru.isiste'atis, terstruktur yan 'e'penaru.ie*ekti+itas 'utu, pe'enu.an dan i'ple'entasie*ekti+itas 'utu, pe'enu.an dan i'ple'entasiter.adap standar yan tela. ditetapkanter.adap standar yan tela. ditetapkan

se(elu'nyase(elu'nya AUDI> ;IN<7UN<ANAUDI> ;IN<7UN<AN untuk 'enentukan apaka. se'ua atau tinkatuntuk 'enentukan apaka. se'ua atau tinkat

yan ada dala' suatu oranisasi tela.yan ada dala' suatu oranisasi tela.'e'enu.i persyaratan, peraturan dan ke(iakan'e'enu.i persyaratan, peraturan dan ke(iakan

serta standar internalserta standar internal



AUDI> MDISAUDI> MDIS

adalah merua!a" !e#$a%a" &a"#adalah merua!a" !e#$a%a" &a"#

'$'%ema%$! &a"# d$la!u!a" (leh'$'%ema%$! &a"# d$la!u!a" (leh

peer peer &a"# %erd$r$ dar$ !e#$a%a"&a"# %erd$r$ dar$ !e#$a%a"

re)$e*re)$e*++ 'ur)e$lla",e'ur)e$lla",e da"da"a''e''me"%a''e''me"% %erhada ela&a"a"%erhada ela&a"a"

med$'med$'

Pe'(a.asan kasus dala' praktekPe'(a.asan kasus dala' praktek

se.ari.ari dapat dianap se(aaise.ari.ari dapat dianap se(aai

audit 'edis yan palin seder.anaaudit 'edis yan palin seder.ana



AUDI> MDIS +s AUDI> R7AMAUDI> MDIS +s AUDI> R7AM

MDISMDIS

Audit reka' 'edisAudit reka' 'edisDilakukan ole. petuas reka' 'edisDilakukan ole. petuas reka' 'ediskelenkapan penisian reka' 'ediskelenkapan penisian reka' 'edis

sedankansedankanAAudit 'edisudit 'edisdilakukan ole. sta* 'edisdilakukan ole. sta* 'edis

denan 'eli.at dianose dandenan 'eli.at dianose danpeno(atan yan terdoku'entasi dala'peno(atan yan terdoku'entasi dala'reka' 'edis terse(ut tela. sesuaireka' 'edis terse(ut tela. sesuaidenan standar atau (elu'denan standar atau (elu'



>U@UAN AUDI> >U@UAN AUDI>

Tu-ua" umum .Tu-ua" umum . >er)apainya pelayanan 'edik pri'a di >er)apainya pelayanan 'edik pri'a di RSRS

Tu-ua" !hu'u' .Tu-ua" !hu'u' .Melakukan e+aluasi 'utu pelayananMelakukan e+aluasi 'utu pelayanan

'edis'edis

Meneta.ui penerapan standarMeneta.ui penerapan standar

pelayanan 'edispelayanan 'edisMelakukan per(aikanper(aikanMelakukan per(aikanper(aikan

pelayanan 'edis sesuai ke(utu.anpelayanan 'edis sesuai ke(utu.an

pasien dan standar pelayanan 'edispasien dan standar pelayanan 'edis



=R<ANISASI=R<ANISASI

Aud$%(rAud$%(r adala. oran yanadala. oran yan

'elakukan audit'elakukan audit 7=MI> MDIS7=MI> MDIS

SUB7=MI> PNIN<7A>AN MU>U MDISSUB7=MI> PNIN<7A>AN MU>U MDIS

SUB7=MI> AUDI> MDISSUB7=MI> AUDI> MDIS

S7 DIR7>UR RUM7I>S7 DIR7>UR RUM7I>

;IBA>7AN R7AM MDIS, SM, B=;;IBA>7AN R7AM MDIS, SM, B=;

PA7AI 7=NSU;>ANPA7AI 7=NSU;>AN



PRSIAPANPRSIAPAN

BN>U7 >IM AUDI>BN>U7 >IM AUDI>PD=MAN AUDI>PD=MAN AUDI>

S=P AUDI>S=P AUDI>

7RI>RIA DAN S>ANDAR 7ASUS 0<7RI>RIA DAN S>ANDAR 7ASUS 0<

DIAUDI>DIAUDI>

DISUMPADISUMPA

BUDA0A7AN P;AND=""7A">I=NBUDA0A7AN P;AND=""7A">I=NPN<ISIAN R7AM MDIS ARUSPN<ISIAN R7AM MDIS ARUS

;N<7AP DAN >PA> ?A7>U;N<7AP DAN >PA> ?A7>U



P;A7SANA AUDI>P;A7SANA AUDI>

DAPA> DUA "ARA:DAPA> DUA "ARA: >IM D=7>R A;I >R7AI> >IM D=7>R A;I >R7AI>

>IM P;A7SANA DN<AN >IM P;A7SANA DN<AN

MN<<UNA7AN 7RI>RIA 0< DIBUA>MN<<UNA7AN 7RI>RIA 0< DIBUA>

>IM D=7>R A;I >IM D=7>R A;I

DISUMPA @A<A RAASIADISUMPA @A<A RAASIA

N=N B;AMIN<N=N B;AMIN<

=B07>I, INDPNDN=B07>I, INDPNDN



DSAIN AUDI>DSAIN AUDI>

>U@UAN >U@UAN

?A7>U?A7>U

7RI>RIAS>ANDAR7RI>RIAS>ANDAR ;I>RA>UR PNDU7UN< 7RI>RIA;I>RA>UR PNDU7UN< 7RI>RIA

7RI>RIA ?A@IB DAN >AMBAAN7RI>RIA ?A@IB DAN >AMBAAN

@AMIN A<AR DAPA> MN<U7UR 0ANMD @AMIN A<AR DAPA> MN<U7UR 0ANMD

S>RA><I PN<UMPU;AN DA>AS>RA><I PN<UMPU;AN DA>A

PN>APAN SAMP;IN<PN>APAN SAMP;IN<

ANA;ISISANA;ISIS



PN<UMPU;AN DA>APN<UMPU;AN DA>A

DAPA> DI;A7U7AN PI;=> S>UD0DAPA> DI;A7U7AN PI;=> S>UD0MN<U@I APA7A PN<UMPU;AN DA>AMN<U@I APA7A PN<UMPU;AN DA>A

MUDA, R;CAN DAN "U7UPMUDA, R;CAN DAN "U7UP

7=MPU>RISASI MMUDA7AN7=MPU>RISASI MMUDA7AN

MINIMA; DA>A >>API "U7UPMINIMA; DA>A >>API "U7UP

@A<A 7RAASIAAN: @A<A 7RAASIAAN:AN=NIMAN=NIM

>RBA>AS >RBA>AS



ASI; AUDI> E RAUDI>ASI; AUDI> E RAUDI>

APA7A P;A0ANAN 0< A7AN DINI;AIAPA7A P;A0ANAN 0< A7AN DINI;AI >;A "U7UP >RNI;AI>RU7UR >;A "U7UP >RNI;AI>RU7URDAN DAPA> DIANA;ISISDAN DAPA> DIANA;ISIS

PRSN>ASI SBA<AI DBA"7 PRSN>ASI SBA<AI DBA"7 ASP7 PMB;A@ARAN ;SS=NASP7 PMB;A@ARAN ;SS=N

;ARND6 >R"APAI;ARND6 >R"APAI

PN<U7URAN DAN >AR<>PN<U7URAN DAN >AR<>PN"APAIAN PNIN<7A>AN MU>UPN"APAIAN PNIN<7A>AN MU>UDI>N>U7AN UN>U7 RAUDI>DI>N>U7AN UN>U7 RAUDI>



PR=SS >RD=7UMN>ASIPR=SS >RD=7UMN>ASI



PNN>UAN >=PI7 PNN>UAN >=PI7

PN0A7I> >R>N>UPN0A7I> >R>N>UMISA;N0A : APNDISI>IS A7U>MISA;N0A : APNDISI>IS A7U>

>INDA7AN >R>N>U >INDA7AN >R>N>U

MISA;N0A : S">I= "ASARA ;7>IMISA;N0A : S">I= "ASARA ;7>IPN<<UNAAN =BA> >R>N>UPN<<UNAAN =BA> >R>N>UMISA;N0A : AN>IBI=>I7AMISA;N0A : AN>IBI=>I7A

RISI7= >R>N>URISI7= >R>N>UMISA;N0A F IN7SI N=S=7=MIA;MISA;N0A F IN7SI N=S=7=MIA;

7MA>IAN >R>N>U7MA>IAN >R>N>U

MISA;N0A: 7MA>IAN PADA DMISA;N0A: 7MA>IAN PADA D



"=N>=: <NRA; ADCRS CN>"=N>=: <NRA; ADCRS CN>

INDI"A>=RSINDI"A>=RS

RA?A> INAP - BU;AN 0;RA?A> INAP - BU;AN 0; RA?A> INAP DN<AN INDI7ASI ADAN0ARA?A> INAP DN<AN INDI7ASI ADAN0A

ADCRS CN>SADCRS CN>S >RAUMA >R@ADI DI RS >RAUMA >R@ADI DI RS R=PRASI 0AN< >A7 DIRN"ANA7ANR=PRASI 0AN< >A7 DIRN"ANA7AN PN<AN<7A>AN =R<AN 0< >A7PN<AN<7A>AN =R<AN 0< >A7

DIRN"ANA7ANDIRN"ANA7AN IN7SI ;U7AIN7SI ;U7ADISI> NR=;=<IS S;AMA PRA?A>ANDISI> NR=;=<IS S;AMA PRA?A>AN 7MA>IAN UNGP">D DI RS7MA>IAN UNGP">D DI RS

Mills D, 1!&&



"=N>=:"=N>=:

INDI7A>=R DA;AM =BS>>RI7 INDI7A>=R DA;AM =BS>>RI7 IBUIBU

7MA>IAN IBU7MA>IAN IBU

MASU7 I"UMASU7 I"U

7@AN<7@AN< MASA;A ANS>SIMASA;A ANS>SI

PRDARAAN PR;UPRDARAAN PR;U

>RANSUSI >RANSUSI

S" >;A> #$ MNI>S" >;A> #$ MNI> >RAUMA @ARIN<AN >RAUMA @ARIN<AN

ANA7 ANA7

7MA>IAN N=NA>A;7MA>IAN N=NA>A;

;AIR MA>I;AIR MA>I

AP<AR 3 MINS: H 4AP<AR 3 MINS: H 4 PARA;ISISPARA;ISIS

PA>A >U;AN<PA>A >U;AN<

ASPIRASI M7=NUMASPIRASI M7=NUM

IA>R=<NI" IN@UR0IA>R=<NI" IN@UR0 DIS>=SIA BAUDIS>=SIA BAU

;uon and Se)ker ?alker, 1!!!



S>ANDAR E 7RI>RIAS>ANDAR E 7RI>RIA

@;AS, =B07>I, RIN"I, BRBASIS @;AS, =B07>I, RIN"I, BRBASIS

BU7>IBU7>IMISA;N0A: BA<AIMANA DIA<N=SISMISA;N0A: BA<AIMANA DIA<N=SIS

DI><A77AN, 7RI>RIA 7ASUS 0<DI><A77AN, 7RI>RIA 7ASUS 0<DIAUDI>, PR=SDUR >INDA7AN,DIAUDI>, PR=SDUR >INDA7AN,

PNI;AIAN ASI; >RAPI, D;;PNI;AIAN ASI; >RAPI, D;;

7RI>RIA: MUS> D=J MINIMUM 7RI>RIA67RI>RIA: MUS> D=J MINIMUM 7RI>RIA6

DAN S=U;D D=J >AMBAAN6DAN S=U;D D=J >AMBAAN6

PN<U7URAN PNI;AIANPN<U7URAN PNI;AIAN



AN/INAAN/INA

Summar& (0 ,r$%er$a+Summar& (0 ,r$%er$a+

11MUST DO” CRITERIAMUST DO” CRITERIATe re#ords sow tat te d"a!nos"s of an!"naTe re#ords sow tat te d"a!nos"s of an!"na

"s based on ,a- #ara#ter"st"# s&m'toms of"s based on ,a- #ara#ter"st"# s&m'toms of

an!"na or ,b- su!!est"ve s&m'toms of an!"naan!"na or ,b- su!!est"ve s&m'toms of an!"naw"t 'os"t"ve "nvest"!at"ve 2nd"n!s.w"t 'os"t"ve "nvest"!at"ve 2nd"n!s.

Te re#ords sow tat at d"a!nos"s te b$oodTe re#ords sow tat at d"a!nos"s te b$ood

'ressure as been re#orded and te 'at"ent 'ressure as been re#orded and te 'at"ent

e)am"ned for s"!ns of anem"a and as ae)am"ned for s"!ns of anem"a and as a#ard"a# e)am"nat"on#ard"a# e)am"nat"on

Te re#ords sow tat te 'at"ent "s on da"$&Te re#ords sow tat te 'at"ent "s on da"$&

as'"r"n un$ess #ontra"nd"#atedas'"r"n un$ess #ontra"nd"#ated



Te re#ords sow tat at $east annua$$& tereTe re#ords sow tat at $east annua$$& tere

as been an assessment of smok"n! ab"tas been an assessment of smok"n! ab"tand adv"#e !"ven to smokersand adv"#e !"ven to smokers

Te re#ords sow tat at d"a!nos"s teTe re#ords sow tat at d"a!nos"s te

'at"ent3s b$ood $"'"ds ave been #e#ked 'at"ent3s b$ood $"'"ds ave been #e#ked

Te re#ords sow tat at $east annua$$& teTe re#ords sow tat at $east annua$$& teb$ood 'ressure as been #e#ked and "sb$ood 'ressure as been #e#ked and "s

w"t"n norma$ $"m"tsw"t"n norma$ $"m"ts

Te re#ords sow tat tere "s an annua$Te re#ords sow tat tere "s an annua$assessment of s&m'tomsassessment of s&m'toms



AN/INAAN/INA

Summar& (0 ,r$%er$a+Summar& (0 ,r$%er$a+

“ “ SHOULD DO” CRITERIASHOULD DO” CRITERIATe re#ords sow tat at $east annua$$&Te re#ords sow tat at $east annua$$&

re!u$ar '&s"#a$ a#t"v"t& as beenre!u$ar '&s"#a$ a#t"v"t& as been

d"s#ussed w"t te 'at"ent d"s#ussed w"t te 'at"ent

Te re#ords sow tat te bod& massTe re#ords sow tat te bod& mass

"nde) "s #e#ked at d"a!nos"s"nde) "s #e#ked at d"a!nos"sTe re#ords sow tat te 'at"ent asTe re#ords sow tat te 'at"ent as

ad a rest"n!ad a rest"n! 12 lead "<12 lead "<



SAMP;IN<SAMP;IN<

PR>IMBAN<7AN R7UNSI 7ASUS,PR>IMBAN<7AN R7UNSI 7ASUS,

SIA> 7ASUS A7U>7R=NI76, SIA>SIA> 7ASUS A7U>7R=NI76, SIA>

>INDA7AN>RAPI 0< DIAUDI>, D;; >INDA7AN>RAPI 0< DIAUDI>, D;;

PR;U7A RAND=M A>AU7A "U7UPPR;U7A RAND=M A>AU7A "U7UP

7=NS7U>IPURP=SI7=NS7U>IPURP=SI

A7IR PN<UMPU;AN 7ASUS:A7IR PN<UMPU;AN 7ASUS:

@UM;A >R"APAI A>AU ?A7>U @UM;A >R"APAI A>AU ?A7>U

ABISABIS



ANA;ISISANA;ISIS

ANA;ISIS, PISA7AN 7ASUS 0< >IDA7ANA;ISIS, PISA7AN 7ASUS 0< >IDA7SSUAI S>ANDAR 0ANMDSSUAI S>ANDAR 0ANMD

ANA;ISIS MN<APA >IDA7 SSUAIANA;ISIS MN<APA >IDA7 SSUAI

R==> "AUS ANA;0SISR==> "AUS ANA;0SISADA7A PMBNAR A>AU PMAAADA7A PMBNAR A>AU PMAA"ARI MASA;A MANA@MN 0ANMD DAN"ARI MASA;A MANA@MN 0ANMD DAN

7=N>RIBU>=RN0A SBA<AI A7>=R RISI7=7=N>RIBU>=RN0A SBA<AI A7>=R RISI7=CA;UASI RISI7=CA;UASI RISI7=

USU;AN UPA0A 7=R7SIUSU;AN UPA0A 7=R7SI



A7>=RA7>=R22 DA;AMDA;AM RAM?=R7 RAM?=R7

INDIVIDUAL 2STAFF3 FACTORSINDIVIDUAL 2STAFF3 FACTORS7N=?;D<S AND S7I;;S7N=?;D<S AND S7I;;S"=MP>N""=MP>N"P0SI"A; AND MN>A; A;>P0SI"A; AND MN>A; A;>

TASK FACTORSTASK FACTORS >AS7 DSI<N AND ";ARI>0 = S>RU">URS >AS7 DSI<N AND ";ARI>0 = S>RU">URSACAI;ABI;I>0 AND US = PR=>="=;SACAI;ABI;I>0 AND US = PR=>="=;SACAI;ABI;I>0 AND A""URA"0 = >S> RSU;>SACAI;ABI;I>0 AND A""URA"0 = >S> RSU;>S

PATIENT FACTORSPATIENT FACTORS"=NDI>I=NS "=MP;GI>0 AND SRI=USNSS6"=NDI>I=NS "=MP;GI>0 AND SRI=USNSS6 ;AN<UA< AND "=MMUNI"A>I=NS;AN<UA< AND "=MMUNI"A>I=NSPRS=NA;I>0 AND S="IA; A">=RSPRS=NA;I>0 AND S="IA; A">=RS

Cin)ent ", >aylorAda's S, 2$$1



INSTITUTIONAL CONTE4TINSTITUTIONAL CONTE4T "=N=MI" AND R<U;A>=R0 "=N>G>"=N=MI" AND R<U;A>=R0 "=N>G> NA>I=NA; A;> SRCI" G"U>ICNA>I=NA; A;> SRCI" G"U>IC ";INI"A; N<;I<N" S"M =R >RUS>S";INI"A; N<;I<N" S"M =R >RUS>S

OR/ANI5ATIONAL 6 MANA/EMENT FACTORSOR/ANI5ATIONAL 6 MANA/EMENT FACTORS INAN"IA; RS=UR"S AND "=NS>RAIN>SINAN"IA; RS=UR"S AND "=NS>RAIN>S =R<ANI8A>I=NA; S>RU">UR=R<ANI8A>I=NA; S>RU">UR P=;I"0 S>ANDARDS AND <=A;SP=;I"0 S>ANDARDS AND <=A;S SA>0 "U;>UR AND PRI=RI>ISSA>0 "U;>UR AND PRI=RI>IS

WORK ENVIRONMENT FACTORSWORK ENVIRONMENT FACTORS S>AIN< ;C;S AND S7I;;S MIGS>AIN< ;C;S AND S7I;;S MIG ?=R7;=AD AND SI> PA>>RNS?=R7;=AD AND SI> PA>>RNS DSI<N, ACAI;ABI;I>0 AND MAIN>NAN"DSI<N, ACAI;ABI;I>0 AND MAIN>NAN" ADMINIS>RA>IC AND MANA<RIA; SUPP=R>ADMINIS>RA>IC AND MANA<RIA; SUPP=R>

TEAM FACTORSTEAM FACTORS CRBA; AND ?RI>>N "=MMUNI"A>I=NCRBA; AND ?RI>>N "=MMUNI"A>I=N SUPRCISI=N AND S7IN< ;PSUPRCISI=N AND S7IN< ;P >AM S>RU">UR "=NSIS>N"0, ;ADRSIP, >"6 >AM S>RU">UR "=NSIS>N"0, ;ADRSIP, >"6

Cin)ent ", >aylorAda's S, 2$$1



RIS7 ANA;0SISRIS7 ANA;0SIS

S=UR"S = RIS7 S=UR"S = RIS7 "=NS5UN"S E ;I7;I==D"=NS5UN"S E ;I7;I==DPAS> R"=RDSPAS> R"=RDS

R;CAN> GPRIN"SR;CAN> GPRIN"SR;CAN> PUB;ISD ;I>RA>URSR;CAN> PUB;ISD ;I>RA>URSSP"IA;IS> AND GPR> @UD<MN>,SP"IA;IS> AND GPR> @UD<MN>,

>">"

GIS>IN< "=N>R=;GIS>IN< "=N>R=;MANA<MN>, >"NI"A; S0S>M,MANA<MN>, >"NI"A; S0S>M,

PR="DURSPR="DURS



;C;C;;

DS"RIP>=DS"RIP>=RR

GAMP; D>AI;GAMP; D>AI;

11 InsiniK)anInsiniK)an

ttNo inuries, lo/ Knan)ialNo inuries, lo/ Knan)ial

lossloss

22 MinorMinor irst aid treat'ent,irst aid treat'ent,

'ediu' Knan)ial loss'ediu' Knan)ial loss

## ModerateModerate Medi)al treat'entMedi)al treat'ent

reLuired, .i. Knan)ialreLuired, .i. Knan)iallossloss

44 MaorMaor tensi+e inuries, loss o*tensi+e inuries, loss o*

produ)tion )apa(ility,produ)tion )apa(ility,

5UA;I>A>IC MASURS = "=NS5UN"S



;C;C;;

DS"RIP>=DS"RIP>=RR

DS"RIP>I=NDS"RIP>I=N

AA Al'ostAl'ost

)ertain)ertainIs epe)ted to o))ur inIs epe)ted to o))ur in

'ost )ir)u'stan)es'ost )ir)u'stan)es

BB ;ikely;ikely ?ill pro(a(ly o))ur in?ill pro(a(ly o))ur in

'ost )ir)u'stan)es'ost )ir)u'stan)es

"" Possi(lePossi(le Mi.t o))ur at so'eMi.t o))ur at so'e

ti'eti'eDD UnlikelyUnlikely "ould o))ur at so'e"ould o))ur at so'e

ti'eti'e

RareRare May o))ur only inMay o))ur only in

5UA;I>A>IC MASURS = ;I7;I==D



likeli.oodlikeli.ood 11insininsin

22'inor'inor

##'oderat'oderat

ee

44'aor'aor

33)atast.)atast.

rr

AA al'ostal'ost

)ertain6)ertain6

BB likely6likely6 MM

"" 'oderate6'oderate6 ;; MM

DD unlikely6unlikely6 ;; ;; MM

rare6rare6 ;; ;; MM

)onseLuen)es

5UA;I>A>IC RIS7 ANA;0SIS MA>RIG ;C; =RIS7

: tre'e risk, i''ediate a)tion reLuired

: i. risk, senior 'anae'ent attention needed

M: 'oderate risk, 'anae'ent responsi(ility 'ust (e

spe)iKed



RIS7 >RA>MN>RIS7 >RA>MN>

AC=ID > RIS7 AC=ID > RIS7

RDU" > ;I7;I==DRDU" > ;I7;I==D

RDU" > "=NS5UN"SRDU" > "=NS5UN"S >RANSR > RIS7 >RANSR > RIS7

R>AIN > RIS7 R>AIN > RIS7



>INDA7AN 7=R7>I >INDA7AN 7=R7>I

4NGIN44RING SO5UTION4NGIN44RING SO5UTIONMN0DIA7AN 0< >ADIN0A >IDA7 ADA,MN0DIA7AN 0< >ADIN0A >IDA7 ADA,

MMPRBAI7IMN<<AN>I 0AN< RUSA7,MMPRBAI7IMN<<AN>I 0AN< RUSA7,

A>AU BUAN< PN0BAB, MISA;N0A:A>AU BUAN< PN0BAB, MISA;N0A:BAN<UN ASI;I>AS 0< AD7UA>BAN<UN ASI;I>AS 0< AD7UA>B;I PRA;A>AN 0< 7URAN< >A7 ADAB;I PRA;A>AN 0< 7URAN< >A7 ADASDIA7AN A;IN0ASDIA7AN A;IN0AP"A> PRS=NI; 0< >IDA7 7=MP>NP"A> PRS=NI; 0< >IDA7 7=MP>N

M=S> DSIRAB;, BU> GPNSIC ANDM=S> DSIRAB;, BU> GPNSIC AND >IM "=NSUMIN<: >IM "=NSUMIN<:

?==D R A+iation Sa*ety Prora's, a 'anae'ent .and(ook, nle/ood:



>INDA7AN 7=R7>I 2 >INDA7AN 7=R7>I 2

CONTRO5 SO5UTIONCONTRO5 SO5UTIONBAA0A >>AP ADA, >API "ARI P;INDUN<BAA0A >>AP ADA, >API "ARI P;INDUN<

A>AU PR=SDUR IN<<A 7I>A >IDA7A>AU PR=SDUR IN<<A 7I>A >IDA7 >RPAPAR RISI7= >RPAPAR RISI7=

64RSONN45 SO5UTION64RSONN45 SO5UTIONBAA0A >>AP ADA, >API BRI PRIN<A>ANBAA0A >>AP ADA, >API BRI PRIN<A>AN

7PADA P;A7SANA A<AR >IDA7 >RPAPAR7PADA P;A7SANA A<AR >IDA7 >RPAPAR

6ROT4CTI74 48UI694NT SO5UTION6ROT4CTI74 48UI694NT SO5UTIONBAA0A >>AP ADA, 0AN< DIRDU7SIBAA0A >>AP ADA, 0AN< DIRDU7SI

AN0A DAMPA7N0AAN0A DAMPA7N0A

?==D R A+iation Sa*ety Prora's, a 'anae'ent .and(ook, nle/ood:



P;AP=RANP;AP=RAN

7ASUS7ASUSDIA<N=SISDIA<N=SISURAIAN, PRA7>I7 0< BAI7, MASA;AURAIAN, PRA7>I7 0< BAI7, MASA;A

0ANMD, 7SSUAIAN D< S>ANDAR 0ANMD, 7SSUAIAN D< S>ANDARPNAN<ANANPNAN<ANANURAIAN, PRA7>I7 0< BAI7, MASA;AURAIAN, PRA7>I7 0< BAI7, MASA;A

0ANMD, 7SSUAIAN D< S>ANDAR 0ANMD, 7SSUAIAN D< S>ANDARUSU;AN 7=R7SIUSU;AN 7=R7SI7SIMPU;AN DAN SARAN7SIMPU;AN DAN SARAN

bs medical audit 2006 - 8

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