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1 Patient Safety Patient Safety Anwar Wardy W Anwar Wardy W Center For Bioethics, Medicolegal and Humanities Center For Bioethics, Medicolegal and Humanities Aspect…….//HELP Aspect…….//HELP FK.UMJ FK.UMJ anwar wardy w anwar wardy w center for help center for help aspect,...fk.umj aspect,...fk.umj

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1 1Patient Patient SafetySafetyAnwar Wardy W Anwar Wardy WCenter For Bioethics, Medicolegal and HumanitiesCenter For Bioethics, Medicolegal and Humanities Aspect.//HELP Aspect.//HELPFK.M! FK.M!anwar wardy w anwar wardy w center for help aspect,...fk.umj center for help aspect,...fk.umj2 2PATIENT SAFETY DOMAINS KNOWLEDGE, SKILLS, ATTITUDES1. Theoretical Foundations Microsystems, historical trends, chaos, complexity, competency and learning2.Behavioral Aspects of MedicalProfessionalism thics, patient !uality of life, resolution of conflict ".#nterpersonal #ssues $ommunication, stress and coping%.&uman Factors and rgonomics'esign history, error taxonomies, safety tools, decision support systems, fatigue factors, user centered design(.)ystems Analysis *sa+ility criteria , organi,ations and learning disasters, place for human error-..#/earningPareto0flo1 charts, and other .# tools, +est practices, act cycles2.#n3ury pidemiology 4or5place ha,ards, 1or5er safety,phases of in3ury, medico6legal aspects7.Medication )afety Adverse and near6miss reporting, #)MP tools and 1e+site, loo50sound6ali5es8.$risis Management Tools Team 1or5, shared decision ma5ing, situational a1areness19. )imulations Micro6, macro6, de+riefing, immersion levels, scripting, role playingTHE PATIENT SAFETY CURRICULUMGilula, M. and Barach P. Creating a Patient Safety Curriculum: Purposive Sampling of Patient Safety Experts. 79th Clinical and Scientific IARS Congress. S-143. Honolulu, Hawaii. March 12, 2005.; Gilula, Barach, 2007.anwar wardy w anwar wardy w center for help aspect,...fk.umj center for help aspect,...fk.umj3 3Background on Patient Background on Patient Safety and Patient Safety and Patient Safety Core CurriculumSafety Core Curriculumanwar wardy w anwar wardy w center for help aspect,...fk.umj center for help aspect,...fk.umjMengapa Patient Safety Process of care Process of care Outcome Outcome Structure Structure: AEBlaming-Pengaduan, Tuntutan-Tuduhan Malpraktek(Pid/Perd)-Proses Hukum:Polisi,Pengadilan-Blow-up Mass Media, !" Pu#likasi-opini negati$-Pertahanan %& :-Penga'ara-%&/(r : )suransi-Tuntutan #alik- (s#Patient Safety-*ulture-%eporting-+earning/Analysis/Research-,-%-#ased &tandard-.uideline-/mplementasi,Monitor-Patient /n0ol0ementCostlyKecurigaan meningkatKepercayaan meningkatCost: n!sment"uality "uality "uality1i'o )2 +umenta/,,P-%&bioetika, makersi; fkkbioetika, makersi; fkk umj umj anwar wardy w anwar wardy wKONSEP DASAR KONSEP DASAR PATIENT SAFETYPATIENT SAFETYbioetika, makersi; fkkbioetika, makersi; fkk umj umj anwar wardy w anwar wardy wPatient "a#et$ adalah isu ter%ini, glo&al, penting 'high pro(le), dalam Pela$anan *", pra%tis &elum lama,dimulai se+a% ,Landmar%- Laporan ./M th 0111. 2H/ memulai Program Patient "a#et$th 0113 42H/ memulai Program Patient "a#et$th 0113 4 , ,"a#et$ is a #undamental principle o# patient "a#et$ is a #undamental principle o# patientcare and care anda critical component o#5ualit$ management. a critical component o#5ualit$ management.- - (World(World Alliance for PatientSafety, Forward ProgrammeWHO,2004) Alliance for PatientSafety, Forward ProgrammeWHO,2004) K/M.6E KE"ELAMA6A7 PA".E7 *MAH "AK.6 K/M.6E KE"ELAMA6A7 PA".E7 *MAH "AK.6'KKP8 'KKP8*") *")di&entu%PE*"., pd tgl 9 !uni011: ME76E*. KE"EHA6A7 &ersama PE*". ; KKP8*" telah mencanang%an er?does Medication Cart =ra>er?does @our Cart Loo% diAerentB@our Cart Loo% diAerentBanwar wardy w anwar wardy w center for help aspect,...fk.umj center for help aspect,...fk.umj11 11,icrosystems -.ist /ithin ,icrosystems -.ist /ithin 0ther Systems0ther SystemsPatient &el$-'are &3stem/ndi0idual 'aregi0er, team and &3stem*lini'al Mi'ros3stemMa'ro4rgani5ation &3stem*ommunit3, Market, &o'ial Poli'3 &3stemanwar wardy w anwar wardy w center for help aspect,...fk.umj center for help aspect,...fk.umj12 12!he !eamS!-PPS !he !eamS!-PPS 1ramework1rameworkKno>ledge Kno>ledge2Shared ,ental ,odel Shared ,ental ,odelAttitudes Attitudes2,utual !rust ,utual !rust2!eam 0rientation !eam 0rientationPer#ormance Per#ormance2)dapta3ility )dapta3ility2)ccuracy )ccuracy2Producti$ity Producti$ity2-4ciency -4ciency2Safety SafetyBaker (, &alas 6, Battles 7, ,ing H, Bara'h P, 8!!9, 8!!:anwar wardy w anwar wardy w center for help aspect,...fk.umj center for help aspect,...fk.umj13 137earning Performing)ssess*ompeten'e;es 1o&imulations+earning Port$olios,nowledge Map*urri'ulum)dapti$e and &e5ecti$e 6ife76ong 6earninganwar wardy w anwar wardy w center for help aspect,...fk.umj center for help aspect,...fk.umj18 18)d$erse -$ent,anagement )d$erse -$ent,anagement PlanPlanActiation EentCrisis !gt "eamContainment #lan Render care to $t %ta&& %u$$ort Contain risk o& 'arm(recurrence Noti&ication %ecuring scene)nestigation * RCACommunication #lan#atientE+ternal Audience)nternal AudienceNoti&, -illing to 'old .illsCorrectie Action * #reentionRecoer,!onitoringRestitutionDisclosure(Organizational Recoer,Immediate ResponseFollow-up Responseanwar wardy w anwar wardy w center for help aspect,...fk.umj center for help aspect,...fk.umj19 19-lements of 0rgani:ational -lements of 0rgani:ational )ccidents)ccidents7ames T2 %eason2 The Human $ord ?ni0ersit3 Press @ATask and 6n0ironmental *onditions/ndi0idual ?nsa$e )'ts4rgani5ational Pro'essesesi tara93. 9E81F813 "ri(%a Modeong *" CM ; *" MMC !%t Keracunan mercur$ ; arsen Ma&es Polri9:. 9E 81F813*as$id *ahman *" CM ; *" MMC !%t Keracunan mercur$ ; arsen Ma&es Polri9G. 9E81F813 !uhria *atu&ahe*" CM ; *" MMC !%t Keracunan Mercur$ ; arsen Ma&es Polribioetika, makersi; fkkbioetika, makersi; fkk umj umj anwar wardy w anwar wardy w9F. 9E 81F813Masna "timan *" CM ; *" MMC !%t Keracunan mercur$ ; arsen Ma&es Polri9E. 0G81F813 *eC$ Anastasia *" Ci%ini !%t Keracunan /&at Polda Metro !a$a9H. 1H 81F813*eC$ Anastasia Apoti% *" Ci%ini !%t Keracunan /&at Polda Metro !a$a01. 9081E813 *as$id *ahman Men%es Ahmad "u+udi Pencemaran nama &ai% dgn Ma&es PolriMentam&en P @usgiantoro men$ata%an td% ada pencemaranMen LH 7a&iel Ma%arim09. 9E 81E813Fellina AJJahra *" Kar$a Medi%a !%t Meninggal %rn salah operasi usus Polda Metro !a$a00. 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