Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

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Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit
 RISK
§ Accreditation compliance
§ Claims management
§ Contract review
§ Corporate and regulatory
compliance
§ Disclosure
§ Enterprise risk management
§ Ethics
§ Legal defense coordination
§ Mandatory event reporting
Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit
PATIENT SAFETY
§ Analysis of adverse and sentinel
events and trends
§ Accreditation issues
§ Board reports
§ Corrective action plans
§ Culture of safety
§ Feedback to providers and staff
§ Patient complaint handling
§ Patient education
§ Patient safety initiatives
QUALITY
§ Accreditation coordination
§ Benchmarking
§ Best practices/ clinical
guidelines
§ Improvement projects
§ Patient satisfaction
§ Peer review
§ Provider and staff performance
and competency
§ Quality-of-care reviews
§ Quality management (e.g., data,
measures, indicators,
dashboards, core measures)
 RISK PATIENT SAFETY QUALITY
§ Patient relations § Proactive risk assessment § Quality methodology

§ Policies and procedures § Provider credentialing § Utilization/resource/case

management

§ Risk control (e.g., loss § Public reporting of quality data

prevention and loss reduction)
§ Risk financing (including § Root-cause analysis
insurance purchasing and
management)
§ Risk identification (including § Staff education and training
near-miss and adverse event
reporting)
§ Safety and security
§ Workers’ compensation

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

Murphy’s Law : Anything that can go wrong.....will go wrong
 TYPE OF SENTINEL EVENT

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

§ Despite sustained efforts by the healthcare industry to improve
patient safety over the last two decades, medical errors continue to
occur at unacceptable rates globally.
§ A study by Johns Hopkins (2020) showed that
Ø More than 250,000 people in the US die every year due to medical errors
(3rd leading cause of death)
Ø Heart disease (700,000 people)
Ø Cancer (600,000 people)
§ In Australia, Grattan Institute Report (2018) revealed that one in
nine patients suffers a hospital-acquired complication
§ WHO statistics which estimates one in every 10 patients being
harmed while receiving hospital care, of which 50% are preventable.

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

Medication Management and Use

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

Can You Name the Top 10 Patient Safety Risks in Your Hospital?
By: Paul Dughi
May 25, 2022

More than 36 million people are

admitted to hospitals every year in
the U.S. They come to seek
t r e a t m e n t s a n d g e t b e t t e r.
Unfortunately, it doesn’t always go as
p l a n n e d . O n e i n 1 0 p at i e nt s i s
harmed while receiving hospital care,
according to a study by the World
Health Organization of people living
in high-income countries like the U.S.

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

No Patient Safety Risk in Hospital
1. Bloodborne Pathogens 5.9 work-related injuries & illness for every 100 employees

2. Catheter-Associ Urinary Tract Infect (CAUTI) 449,334/year, and 13,000 deaths annually
3. Diagnostic Errors Third lead cause of death in U.S / 10% death
4. Hacked Medical Devices In 2020, 46 hospitals were hit in just 1 attack
5. Venous Thromboembolism (HA-VTE) VTE affects about 900,000 people / year
6. Hospital-Acquired Pneumonia Every day, one out of every 31 patients in U.S
7. Medication Errors 700,000 ED visits & 100,000 hospitalization /year
8. Methicil Resistant Staphyl. Aureus (MRSA) More than 323,000 cases/year & 10,600 deaths.

9. Post-Discharge Adverse Events 20% patients complication within 3 weeks of being discharged

10. Sepsis 1,700,000 get sepsis each year, and about 270,000 die

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit
 LESSON LEARN

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit
ISU NEGATIF PELAYANAN RUMAH SAKIT

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit
Learnings from the Aviation Risk Management
§ Identifying and selecting constructive team leaders and proactive team
members
§ Improving teamwork (communication, team building, and workload
management) skills
§ Providing effective management of stress among health care team personnel
§ Implementing a regulated, taught, practiced, and enforced Code of Mutual
respect
§ Encouraging interdisciplinary awareness and education
§ Providing conflict management training
§ Providing simulations, trainings, and recurrent trainings about clinical
scenarios
§ Implementing nonpunitive reporting systems (except for intentional
noncompliance
Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit
Why Do Adverse Events Keep Happening?

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit
 1.

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

2. HUMAN RESOURCES
3. PATIENT SAFETY CULTURE
BLAME DOESN’T MAKE US SAFE

Professor at the Harvard School of Public Health

and a leader in the patient safety field

Only 45% of NHS staff believe that their organisation treats people fairly after a safety incident
NHS Staff Survey, 2017

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

SECOND VICTIMS

Health care professionals too often had to cope

by themselves following medical errors, near-
misses and other stressful patient-related events.
These employees risked a host of symptoms,
such as difficulty sleeping, depression,
flashbacks and self-doubt harming not only their
health but also threatening their ability deliver
safe, compassionate care.

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

4. QUALITY & RISK MANAGEMENT
Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit
INDIKATOR MUTU PRIORITAS UNIT ( IMP-UNIT)
 INDIKATOR KESELAMATAN PASIEN

1. Kepatuhan identifikasi pasien sebelum diambil sampel darah

2. Kepatuhan penulisan lengkap komunikasi efektif oleh PPA
3. Kepatuhan dilakukan double check pemberian obat high alert
4. Kepatuhan dilakukan time out sebelum tindakan medik
5. Kepatuhan dilakukan cuci tangan oleh dokter sebelum memeriksa
pasien
6. Kepatuhan dilakukan pengelolaan risiko jatuh pada pasien ranap

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit
 MONITORING & EVALUATION

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

 PATIENT JOURNEY

Systems - Care - Interactions - Environment

Lembaga Akreditasi Mutu Dan Keselamatan Pasien Rumah Sakit

 PATIENT INVOLVEMENT

The Patient Experience Book, NHS Institute

for Innovation and Improvement’s
guidance and support

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

Lembaga Akreditasi Mutu Dan Keselamatan Pasien Rumah Sakit
Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit
LEARN TO TRUST…

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit

 IF YOU CAN’T MEASURE IT
YOU CAN’T IMPROVE IT
PETER F. DRUCKER

SAFET SAFETY CULTURE is not an act, it is HABIT

Lembaga Akreditasi Mutu dan Keselamatan Pasien Rumah Sakit