insiden rumah sakit
DESCRIPTION
ghTRANSCRIPT
-
Jan Feb Mar Apr May Jun
AccessDISCHARGE - DELAY/FAILUREDISCHARGE- INAPPROPRIATEDISCHARGE - REFUSALDISCHARGE PLANNING FAILUREDISCHARGE SUMMARY DELAYSELF DISCHARGEFAILURE TO FOLLOW-UPMISSED APPOINTMENTFAILURE TO REFERLACK OF/DELAYED AVAILABILITY OF BEDS (general)LACK OF/DELAYED AVAILABILITY OF BEDS (high dep)TRANSFER - DELAY/FAILURETRANSPORT INAPPROPRIATETRANSPORT - DELAY/FAILUREOTHER
AccidentCONTACT WITH ELECTRICITYEXPOSURE TO HARMFUL SUBSTANCE
Exposure to RadiationExposure to Asbestos
MOVING AND HANDLINGMoving & Handling - Patient/PositioningMoving & Handling - Non-patient
STRUCK BY FALLING OBJECTCONTACT WITH HOT / COLD
Moving & Handling - Display ScreenEquipment Issues
dr. Taufik Santoso www.lean-indonesia.blogspot.com
-
STRUCK BY MOVING VEHICLESLIP/TRIP/FALL
Slip/Trip/Fall on same levelSlip/Trip/Fall from Height
ROAD TRAFFIC ACCIDENTCONTACT WITH FURNITURE/FITTINGSOTHER
Building & Utility IssuesDAMAGED WALLDAMAGED FLOORPLUMBING LEAKGAS LEAKSEWAGE SMELLDOOR LOCKEDEQUIPMENT BROKENDOOR BROKENBLEEP SYSTEM FAILUREFAILURE OF DEVICE/EQUIPMENTDELAY/FAILURE TO PROVIDE EQUIPMENT TO USERIT/TELECOMMUNICATIONS FAILURELACK/UNAVAILABILITY OF DEVICE/EQUIPMENTUSER ERROR OF DEVICE/EQUIPMENTWRONG DEVICE OR EQUIPMENT USEDINADEQUATE CHECK ON EQUIPMENT/SUPPLIESFAILURE/DELAY IN COLLECTION/DELIVERY SYSTEMSOTHER
Clinical Assessment and TreatmentDELAY/DIFFICULTY IN OBTAINING CLINICAL ASSISTANCE
DELAY OBTAINING BLEEP HOLDER OR ON-CALL STAFF
dr. Taufik Santoso www.lean-indonesia.blogspot.com
-
DIAGNOSIS - DELAY/FAILURE TOLACK OF/DELAYED AVAILABILITY OF APPROPRIATE PHYSICIANDIAGNOSIS - WRONG
TREATMENT - DELAY/FAILURE TO MONITORTREATMENT - FAILURE/INCORRECTTREATMENT - FAILURE TO DISCONTINUEPATIENT INCORRECTLY IDENTIFIEDBLOOD TRANSFUSION ERROR
Incorrect DispensingDelay/Problem Obtaining Blood
SCANS/X-RAYS/SPECIMENS - WRONGSCANS/X-RAYS/SPECIMENS - MISSINGSCANS/X-RAYS/SPECIMENS - NOT READTEST REQUEST FORM - NONE/INCOMPLETETEST - FAILURE/DELAY TO UNDERTAKE
TEST RESULTS/REPORT - INCORRECTTEST RESULTS/REPORT - FAILURE/DELAY TO RECEIVETEST RESULTS/REPORT - MISSINGTEST RESULT/REPORT - MISLABELLEDDIETARY ERROR
Wrong PreparationWrong DietFood HazardDelay
SCANS/X-RAYS/SPECIMENS - MISLABELLED/UNLABELLED
TREATMENT - DELAY/FAILURE IN RECOGNISINGCOMPLICATIONS
SCANS/X-RAYS/SPECIMENS - INADEQUATE/INCOMPLETE
TEST RESULTS/REPORT - FAILURE/DELAY TO INTERPRETOR ACT ON
dr. Taufik Santoso www.lean-indonesia.blogspot.com
-
DOCTOR'S INDUCED TREATMENTNOT REFERRED TO SPECIFIC DOCTORNEAR MISSOTHER
CommunityDOG/RAT/HOUSEHOLD PETS/OTHERSSTAFF LOCATION UNKNOWNCAR BREAKDOWNUNHYGIENIC ENVIRONMENTUNSAFE ENVIRONMENTINADEQUATE SUPPORTOTHERDELAY/FAILURE TO PROVIDE SOCIAL CAREDELAY/FAILURE OF CARE AGENCY TO PROVIDE CARE
Financial IssuesWRONG COST ESTIMATIONDOUBLE CHARGEDTARIFF DIFFER BETWEEN THE BOOK AND IN THE SYSTEMWRONG INPUT IN CHARGE SLIPTRANSACTION NOT INPUTEDOTHER
Fire IssuesFIRE (inc. accidental)FIRE ALARM FALSEFIRE ARSON (MALICIOUS)DEFECTIVE FIRE EQUIPMENTOTHER
FAILURE OF RESIDENTIAL CARE HOME TO PROVIDE CARE
dr. Taufik Santoso www.lean-indonesia.blogspot.com
-
Infection Control
FAILURE TO DECONTAMINATE EQUIPMENTINFECTION - CROSS/HEALTHCARE ACQUIREDINFECTION - WOUNDUNSAFE/INAPPROPRIATE CLINICAL ENVIRONMENTUNSAFE/INAPPROPRIATE CLINICAL WASTE ISSUEEXPOSURE TO BODILY FLUIDSNEEDLESTICK INJURY
Dirty Needlestick InjuryClean Needlestick Injury
CUT BY SHARP OBJECT - NOT NEEDLESTICKNOTIFIABLE DISEASEOTHER
InformationFAILURE TO OBTAIN CONSENT
NO ACCESS TO MEDICAL DOCUMENTATIONCONFIDENTIALITY BREACHINCORRECT MENTAL HEALTH ACT RECORDSHEALTHCARE RECORD - DELAY IN OBTAININGHEALTHCARE RECORD - MISLABELLED
REFERRAL - MISSING/INADEQUATE/ILLEGIBLEAPPOINTMENT RECORDING ERRORDOCUMENTATION MISFILED
FAILURE OF STERILISATION OR CONTAMINATION OFEQUIPMENT
HEALTHCARE RECORD -MIXED/MISSING/INADEQUATE/ILLEGIBLE
HEALTHCARE RECORD - NOT SIGNED/DATED BY STAFFCARE PLAN/ASSESSMENT -MISSING/INADEQUATE/ILLEGIBLE
dr. Taufik Santoso www.lean-indonesia.blogspot.com
-
OTHER
IT SecurityVIRUS ATTACKILLEGAL SOFTWAREPASSWORD COMPROMISEDLOSS OF DATALOSS/THEFT OF IT EQUIPMENTE-MAIL CONFIDENTIALITY BREACHEDINTERNET MISUSEOTHER
MaternityUNEXPECTED NEONATAL ADMISSION TO SCBUBIRTH TRAUMA (other)
UNDIAGNOSED CONGENITAL ABNORMALITYOTHER
MedicationPrescribing
ILLEGIBLE PRESCRIPTIONINCORRECT OR INAPPROPRIATE PRESCRIPTIONNO SIGNATUREALLERGY NOT RECORDED
DispensingLABEL ERRORWRONG MEDICINE/STRENGTHWRONG QUANTITYDELAY/PROBLEM OBTAINING MEDICATIONEXPIRED MEDICINE
DELAY IN PAEDIATRICIAN ARRIVING WITHIN 15 MINS OFCALL
dr. Taufik Santoso www.lean-indonesia.blogspot.com
-
AdministrationWRONG PATIENTWRONG MEDICINE
Wrong doseWRONG FORMULATIONWRONG FREQUENCY/RATE/TIMEWRONG ROUTEMEDICINE OMITTEDEXPIRED MEDICINEALLERGY RECORDED BUT TREATMENT GIVENNO RECORD OF ADMINISTRATION
Monitoring and AdviceADVERSE DRUG REACTIONWRONG/OMITTED VERBAL OR WRITTEN ADVICEFAILURE TO MONITOR SIDE EFFECTS/THERAPYFAILURE PATIENT TO FOLLOW DIRECTIONS
Medicine SecurityMEDICINES OBTAINED BY THEFT OR DECEPTIONCONTROLLED DRUG ISSUEDELIVERY/TRANSPORT MEDICATION ISSUEINCORRECT STORAGEMEDICINES MISSING/UNACCOUNTED FORMEDICINES FOUND LOOSE/NOT GIVENMEDICINE KEY ISSUESLEFT UNATTENDED
Other
MAR CHART OR MDS (E.G. DOSSETT) BOX ISSUEINCORRECTLY IDENTIFIED
PATIENT TRANSFERRED OR DISCHARGED WITHNO/INCORRECT MEDICATION/PRESCRIPTION
dr. Taufik Santoso www.lean-indonesia.blogspot.com
-
NEAR MISSOTHER
OrganisationENVIRONMENTAL ISSUE
FloodingOil PollutionEffluent PollutionFood Issue
SERVICE FAILURE (Lighting/Power/Heating etc.)ON CALL SYSTEMS FAILUREOTHER
Security IssuesINTRUDERTHEFT
Theft of Staff PropertyTheft of Trust PropertyTheft of Patient PropertyTheft from/of Staff VehicleTheft from/of Trust (loan) Vehicle
ABSCONDER/MISSING PERSONVANDALISMUNSAFE ENVIRONMENT - (inc PERSONAL SAFETY)LOST OR MISPLACED PROPERTYBOGUS STAFF MEMBERACCIDENTAL DAMAGEFRAUD OR DECEPTIONFORCED ENTRYOTHERSECURITY FALSE ALARM
dr. Taufik Santoso www.lean-indonesia.blogspot.com
-
Service Users IssuesALLERGIC REACTIONDEVELOPED PRESSURE SORES
Pressure ulcer developed within our carePressure ulcer acquired elsewhere
CONCERN OVER A DO NOT RESUSCITATE ORDERUNEXPECTED OR SUSPICIOUS DEATHISSUE CONCERNING PATIENT DIGNITYALCOHOL AND ILLEGAL DRUGS USEDTOURNIQUET PROBLEMCHAPERONE ISSUESPATIENT SELF HARMSUICIDESUICIDE ATTEMPTEDSUDDEN ONSET OF ILLNESSINFUSION SITE
SwollenHaematoma
OTHER
Staffing IssuesINADEQUATE LEVELSINADEQUATE SKILLS MIXCONCERN OVER COMPETENCEINADEQUATE SUPERVISIONACTING BEYOND SCOPE OF PRACTICEOTHER
Surgical / Theatre IssuesTHEATRE LIST DETAILS INCORRECT
DELAY/FAILURE TO START CARDIO PULMONARYRESUSCITATION
dr. Taufik Santoso www.lean-indonesia.blogspot.com
-
LATE AMENDMENTS TO LIST
DIATHERMY BURNTOURNIQUET PROBLEMOPERATION SITE WRONGLY MARKEDWRONG OPERATION PERFORMEDINCORRECT SWAB OR INSTRUMENT COUNTDEEP VEIN THROMBOSIS NO PROPHYLAXISUNPLANNED RETURN TO THEATREUNEXPECTED ACUTE ADMISSIONINCOMPLETE POST-OPERATIVE PREPARATION OF PATIENTCARDIAC ARREST IN OTOTHER
Violence IssuesFIREARMS/DANGEROUS WEAPONSVERBAL (inc telephone)
by otherby patientto staff by staff
PHYSICALby otherby patientto staff by staffHomicide by Patient
RACIALby otherby patientto staff by staff
CHILD ABUSE IdentifiedSEXUAL
INCOMPLETE PRE-OPERATIVE PREPARATION OFPATIENT
dr. Taufik Santoso www.lean-indonesia.blogspot.com
-
by otherby patientto staff by staff
BULLYINGby otherby patientto staff by staff
ADULT ABUSE IdentifiedOTHER (Specify)
dr. Taufik Santoso www.lean-indonesia.blogspot.com