MEMBANGUN KESADARAN AKAN

NILAI KESELAMATAN PASIEN

Prof. DR. dr. Agus Purwadianto, SH, MSi, SpF

Workshop Keselamatan Pasien & Manajemen Risiko Klinis

 Safety is a fundamental
principle of patient care and
a critical component of
quality management.
(World Alliance for Patient Safety, Forward
Programme WHO WHO,2004)
2004)
TUJUH LANGKAH MENUJU KESELAMATAN
PASIEN RUMAH SAKIT
z BANGUN KESADARAN AKAN NILAI KP, Ciptakan kepemimpinan &
budaya yg terbuka & adil.
z PIMPIN DAN DUKUNG STAF ANDA, ANDA Bangunlah
B l h kkomitmen
i & ffokus
k yang
kuat & jelas tentang KP di RS Anda
z INTEGRASIKAN AKTIVITAS PENGELOLAAN RISIKO, Kembangkan
sistem & proses pengelolaan risiko
risiko, serta lakukan identifikasi & asesmen hal
yang potensial bermasalah
z KEMBANGKAN SISTEM PELAPORAN, Pastikan staf Anda agar dgn
mudah dapat melaporkan kejadian / insiden, serta RS mengatur pelaporan
k d KKP
kpd KKP-RS.
RS
z LIBATKAN DAN BERKOMUNIKASI DENGAN PASIEN, Kembangkan cara-
cara komunikasi yg terbuka dgn pasien
z BELAJAR & BERBAGI PENGALAMAN TTG KP KP, Dorong
D staf
t f anda
d utk
tk
melakukan analisis akar masalah untuk belajar bagaimana & mengapa
kejadian itu timbul
z CEGAH CEDERA MELALUI IMPLEMENTASI SISTEM KP KP, Gunakan
informasi yang ada tentang kejadian / masalah untuk melakukan perubahan
pada sistem pelayanan
KKP RS
 BANGUN KESADARAN AKAN NILAI KP
1. Ciptakan kepemimpinan & budaya yg terbuka & adil.
RS:
Kebijakan : tindakan staf segera setetelah insiden, langkah kumpul fakta,
dukungan kepada staf, pasien - keluarga
Kebijakan : peran & akuntabilitas individual pada insiden
Tumbuhkan budaya pelaporan & belajar dari insiden
Lakukan asesmen dengan menggunakan survei penilaian KP.

Tim:
Anggota
ggota mampu
a pu be
berbicara,
b ca a, pedu
peduli & be
berani
a lapor
apo bbilaa ada insiden
s de
Laporan terbuka & terjadi proses pembelajaran serta pelaksanaan tindakan /
solusi yg tepat.
 PATIENT SAFETY
z The process by which an organization makes
patient care safer.
z This should involve:
z risk assessment;
z the
th id
identification
tifi ti andd managementt off patient-
ti t
related risks;
z the
th reportingti andd analysis
l i off iincidents;
id t and d
z the capacity to learn from and follow-up on
incidents and implement solutions to minimize the
risk of them recurring
 KONDISI YG MENDUKUNG
SAFE PRACTICE

1. Communicate the risks

2
2. Guidelines and pathways
3. Human factors engineering
4. W ki time,
Working i stress & ffatigue
i
5. Training and supervision
6. Teams, culture and managing risks
7
7. Safe systems of medical care: risk
management
BANGUN KESADARAN AKAN
NILAI KESELAMATAN PASIEN

Ciptakan kepemimpinan & budaya yg

terbuka & adil

KKP RS
 Kebaruan: Garam

Sodium: terbakar dlm air Clorine: racun Garam: vital untuk manusia

Ekses Kebebasan
Indiv = anarki Blaming culture Lesson &
= persaingan zero sum Learning society
 The key principles
z A safety culture is where staff within an organization
have a constant and active awareness of the
potential for things to go wrong. Both the staff and
the organization are able to acknowledge
mistakes, learn from them, and take action to put
thi
things right.
i ht
z Being open and fair means sharing information
openly and freely,
freely and fair treatment for staff
when an incident happens. This is vital for both the
safety of patients and the well-being
well being of those who
provide their care.
NHS
 The key principles
z 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.
ki
z Looking at what was wrong in the system helps
organizations to learn lessons that can prevent the
incident recurring.

NHS
 The fifth discipline
MENTAL Visi
MODEL Bersama

Pembelajaran
Berpikir Pembelajaran
individu Sistem tim

Keahlian Pembelajaran
Pribadi Tim

Kepedulian nalar pada individu

Sebagai bagian dari sistem sosial
Dengan Saling belajar tanpa
Menimbulkan gejolak, mencapai spiral tertinggi
 Kebudayaan
z Keutuhan sistemik :
z Nilai budaya
z Pandangan hidup
z Norma
z Moral
z Adat Istiadat
z Hukum
z Perilaku
z Ekspresi kebudayaan

= Nilai
Nil i b
bersama-terpilih
t ilih yg maton
t
& mak jegagik dlm sistem etikolegal
 What is a safety culture?

z The culture of an organization is the pattern of beliefs, values,

attitudes,
ttit d norms, unspoken
k assumptions ti and
d entrenched
t h d
processes that shape how people behave and work together.

It is very powerful force and something that remains even when

teams change and individual staff move on.

A safety culture in healthcare is essentially

a culture where staff have a constant and active awareness of the
potential
pote t a for
o things
t gs to go wrong.
o g

It is also a
culture that is open and fair and one that encourages people to
speak up about mistakes.
In organizations with a safety culture people are
able to learn about what is going wrong and then
put things
p g right.
g

In these organizations patient safety is at the

forefront of everyones minds not only when
delivering healthcare but also when setting
objectives developing processes and
objectives,
procedures, purchasing new products and
equipment, and redesigning clinics, wards,
departments and hospitals.

It influences the overall vision, mission and

goals of an organization
 Why is a safety culture important?
Important benefits of a safety culture are:

a potential reduction in the recurrence and in the severity of patient

safetyy incidents through
g increased reporting
p g and organizational
g
learning;

a reduction in the physical and psychological harm patients can suffer

because people are more aware of patient safety concepts, are
working
ki to prevent errors and d are speaking
ki up when
h things
hi go wrong;

a lower number of staff suffering

g from distress,, guilt,
g , shame,, loss of
confidence and loss of morale because fewer incidents are occurring;
 a reduction in the costs incurred for treatment
and extra therapy;

a reduction in resources required for managing

complaints and claims;

a decrease in wider financial and social costs

incurred through patient safety incidents
including lost work time and disability benefits
 BAGAIMANA MEMULAI?
Buatlah survei tentangg isu sbb :
z Bagaimana kemampuan managemen senior melihat
ke depan dan berkomitmen ke arah keselamatan
z Bagaimana komunikasi antara staf dengan manager
z Bagaimana sikap dan perilaku dalam melaporkan
suatu kejadian,
j , blamingg dan p
penghukumannya
g y
z Bagaimana faktor-faktor dalam lingkungan kerja
mempengaruhi kinerja, seperti kelelahan, pengalih
perhatian desain peralatan dan
perhatian,
ketersediaan/kesiapan alat.
 Safety culture assessment
z The first stage in developing a safety culture is to establish the culture
of your organization at present.
z A number of tools are already available to help determine underlying beliefs
beliefs,
attitudes and behaviour.
z Most are in the form of checklists or questionnaires for staff to complete.

z They address a variety of issues, including:

senior management visibility and commitment to safety;
communication between staff and managers;
attitudes to incident reporting, blame and punishment;
factors in the work environment that influence performance (for
example, fatigue, distractions, equipment design or usability)
.
z When choosing a tool to assess safety culture it is important to be aware that
it will provide a snapshot of the culture at one point in time, and you need to
p
repeat the assessment regularly
g y to check yyour p
progress.
g
 TOOLS UNTUK SURVEI
z TYPOLOGICAL TOOLS :
z Checklist for Assessing Institutional Resilience (CAIR )
z Manchester Patient Safety Assessment Tool20 (MaPSaT)
z Advancing Health in America (AHA) and Veterans Health
Association (VHA): Strategies for Leadership. An
organizational Approach to Patient Safety

z DIMENSIONAL TOOLS :
z Safety
S f t Attitudes
Attit d Questionnaire
Q ti i (SAQ)
z Stanford Patient Safety Centre of Inquiry Culture Survey
 contoh

I.
I Background Variables

II Outcome measures
II.
Frequency of Event Reporting

Overall Perceptions of Safety

Patient Safety Grade

Number of Events Reported

 contoh
III. Safety Culture Dimensions (Unit
l
level)
l)
z S
Supervisor/manager
i / expectations
i & actions
i
promoting safety
z Organizational Learning
Learning
Continuous
improvement
z Teamwork Within Hospital Units
z C
Communication O
Openness
z Feedback and Communication About Error
z Non punitive Response To Error
z Staffing
z Hospital Management Support for Patient Safety
 contoh
IV. Safety Culture Dimensions
(H
(Hospital
(Hospital-
i l-wide)
id )
z Teamwork Across Hospital Units
z Hospital Handoffs & Transitions
 MANFAAT SURVEI
z Suatu organisasi perlu mengetahui budayanya
yg sekarang sebelum bisa mengubah budaya
tersebut
z Mengubah sikap dan perilaku itu sulit dan
lama perlu pemahaman tentang keselamatan
lama,
pasien dan pendekatan sistem pada errors
dan incidents
incidents
z Leadership penting dalam membentuk value
d b
dan belief
li f d
dalam
l b
budaya
d
 BUDAYA
KESELAMATAN PASIEN ?
Mengubah Mental Model tentang Sistem

Pendekatan
Inter
dependen

Pendekatan
In
dependen

Uni Multi
Mindless
minded Minded
System
System System
BLAMING vs SAFETY CULTURE
z BLAMING:
z ANALISIS BERAKHIR PADA HUMAN FACTORS
z TINDAKAN: PENGHUKUMAN PIDANA/PERDATA, LUPA
MENGHARGAI
z SIKAP: PERSAINGAN TAK SEHAT, SEMBUNYIKAN KESALAHAN
z SAFETY:
z REPORTING, ANALYSIS, LEARNING,
z PUNISHING BERGERAK KE REWARDING
z TINDAKAN: CARI UPAYA PENCEGAHAN
z SIKAP: BERLOMBA BERBUAT BAIK DAN MENCEGAH YG
BURUK
 Strategi Budaya (Cara Berada Manusia)
Van Peursen
Peursen,
Strategi Karakteristik Manusia Contoh & Implikasi
Budaya
Thp
p Mitis bag tak terpisahkan dr alam/dunia, Pasrah pd kehendak Tuhan,
terkepung kekuatan gaib, takut setan dll,fatalistis
f
Wajib ikuti supranatural utk selamat Minta tolong orang pinter

Thp Ambil jarak dr manus Perilaku ilmuwan

ontologis lain/mahluk/alam Positivistik (p
(percaya
y fakta
Obyektivasi diri & dunia konkrit)
Modern
Thp Sadari relasi dg alam sekitar
sekitar, Pengetahuan yg maslahat
fungsi--
fungsi Tak dpt sepenuhnya ambil jarak krn difungsikan dlm relasi
onal ia ada dlm dunia yg diamatinya
 SIKAP RUMAH SAKIT
z Pastikan RS memiliki kebijakan
j yg menjabarkan
j
apa yg harus dilakukan staf segera setelah
terjadi insiden, bagaimana langkah
pengumpulan
p g p fakta harus dilakukan & dukungan
g
apa yang harus diberikan kepada staf, pasien -
keluarga
z Pastikan RS memiliki kebijakan yg menjabarkan
peran & akuntabilitas individual bilamana ada
insiden
z T b hk budaya
Tumbuhkan b d pelaporan
l & belajar
b l j dari
d i
insiden yang terjadi di RS.
z Lakukan asesmen dengan menggunakan survei
penilaian KP
ANDRAGOGI !!!!!! KKP RS
 SIKAP DALAM TIM
z Pastikan rekan sekerja anda merasa
mampu untuk berbicara mengenai
p
kepedulian mereka & berani melaporkan
p
bilamana ada insiden
z Demonstrasikan kepada
p tim anda ukuran
yang dipakai di RS anda utk memastikan
semua laporan dibuat secara terbuka &
t j di proses pembelajaran
terjadi b l j serta
t
pelaksanaan tindakan / solusi yg tepat

ANDRAGOGI !!!!!! KKP RS

 TERBUKA DAN JUJUR
z staff are open
p about incidents theyy have been involved
in;
z staff and organizations are accountable for their
actions;
i
z staff feel able to talk to their colleagues and superiors
about any incident;
z organizations are open with patients, the public and
staff when
sta e tthings
gs have
a e go
gonee wrong,
o g, a
and
deexplain
p a whatat
lessons will be learned;
z staff are treated fairly and supported when an incident
happens.
ANDRAGOGI !!!!!! NHS
 Being
B i open and d ffair
i ddoes nott
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.
ANDRAGOGI PERLU JUGA KPD MASYARAKAT NHS
 TERBUKA DAN JUJUR
SINGKIRKAN MITOS-
MITOS-MITOS:
z the perfection myth:
bila orangg bekerja
j keras maka mereka tidak akan
membuat errors
z the punishment myth:
bila kita menghukum orang yang melakukan errors
maka akan semakin sedikit pembuat errors, atau
bahwa tindakan pendisiplinan dapat memperbaiki
melalui channelling (BEJANA BERHUBUNGAN)
atau meningkatkan motivasi.

NHS
 Penanganan Insiden
z Staff harus sama persepsinya tentang insiden
z Staff harus tahu apa yang harus dilakukan bila
menemui insiden: mencatat
mencatat, melapor
melapor,
dianalisis, memperoleh feed-
feed-back, belajar dan
mencegah pengulangan
z Staff harus akuntabel dan tahu bagaimana
pendekatan
d k t sistem
i t dan
d personilil
z Bagaimana kalau
ketidaktahuan
mengakibatkan
terlanggarnya
prosedur?
z Lapses or Mistakes?
BAGAIMANA PULA BILA PELANGGARAN DENGAN SENGAJA?
 The systems approach to safety

z All patient safety incidents have four basic

components :

1. CAUSAL FACTORS
2. TIMING
3. CONSEQUENCES
4. MITIGATING FACTORS
.
Each of these components
p should be considered in
the systems approach to safety:

1. Causal factors:
factors: these factors play a significant part in any
patient safety incident. Removing them can prevent or reduce
the chance of a similar incident happening again.
Causal factors are classified into the following groups :

Active
failures: these are actions or omissions that are
sometimes called unsafe
unsafe acts
acts..

Latent system conditions: these are the underlying

rather than
immediate factors that can lead to patient safety incidents.
They relate to aspects of the system in which people work.
2. Timing: this is the point at which the causal factors
combine with failures in the system (defenses or
controls) that lead to an incident
happening.

3. Consequences:
q these are the impact
p an incident
can have, ranging from no harm to the patient to
various levels of severity of harm: low,
moderate,
d t severe and dddeath
th .

4 Mitigating factors:
4. factors some factors
factors, whether
hether actions or
inaction such as chance or luck, may have mitigated
or minimized a more serious outcome
Examples of latent system factors include decisions on:

Planning
Pl i : fixed staffing levels may be adequate until extreme
situations occur, such as more than the usual numbers of staff are on sick
leave, or there are more than the usual number of critically ill
patients;

Designing
Designing:: designing a new clinic, practice, ward or diagnostic centre
without considering vulnerable groups, such as children or mental health
patients, and leaving dangerous equipment within their reach;

Policy
Policy--making
making:: having a strict take-
take-home policy for drugs, which
doesnt take into account difficult times to get to a pharmacy (holidays
such as Christmas) or rare drugs that may not be local stock items;

Communicating
C i ti : having
h i only l a lilimited
it d reporting
ti structure
t t ffor patient
ti t
safety incidents, which means vital lessons are not learned across the
organization
 Violations: these are when individuals or groups deliberately do
not follow a known procedure or choose not to follow a
procedure for a number of reasons
reasons, including:
they may not be aware of the procedure;
the situation dictates a deviation;
it has become habit;
the procedure has been found not to work;
the procedure has been surpassed by a new one but it has yet to be
rewritten.

Contributory factors: these are factors that can contribute to an

incident in relation to:

Patients: these are unique to the patient (s) involved in the incident,
such as the complexity of their condition or factors such as their age or
language;
g g

Individuals: these are unique to the individual (s) involved in the

incident. They include psychological factors, home factors, and work
relationships;
 Tasks: these include aids that support the delivery
of patient care
care, such as policies
policies, guidelines and
procedural documents. They need to be up to date,
available, understandable, useable, relevant and
correct;
t

Communication: these include communication

in all forms: written, verbal and non-
non-verbal.
Communication can contribute to an incident if it is
i d
inadequate,t iineffective,
ff ti confusing,
f i or if it iis ttoo llate.
t
Team and social factors: these can
adversely affect the cohesiveness of a team team. They
involve communication within a team, management
style, traditional hierarchical structures, lack of
respectt for
f less
l senior
i membersb off the
th team
t and d
perception of roles;
.
 Education and training: the availability and quality
of training programmes for staff can directly affect their
ability to perform their job or to respond to difficult or
emergency circumstances.

Equipment
q p and resources: equipment factors
include whether the equipment is fit for purpose, whether
staff know how to use the equipment, where it is stored
anddhhow often
ft it iis maintained.
i t i d

Working conditions and environmental

factors: these affect ability to function at optimum levels
in the workplace
workplace, and include distractions
distractions, interruptions
interruptions,
uncomfortable heat, poor lighting, noise and lack of or
inappropriate use of space.
A Protocol For the Investigation and analysis Of Clinical Incidents.CRU & ALARM
 Why is the systems approach to safety
important?
i t t?
A difficult but essential aspect of a safety culture is the need to
acceptt the
th fact
f t that
th t people,
l processes and d equipment
i t will
ill fail.
f il

By
y doing
g this organizations
g can focus on change
g and developp
defenses and contingency plans to cope with these failures.

Finding out about systems failures in an incident, in addition to

the actions of individuals, will help organizations learn lessons
and potentially stop the same incidents recurring.

Incident Decision Tree (IDT) help organizations adopt the

systems approach after a patient safety incident.
 KATA AKHIR
z Keselamatan Pasien di Rumah Sakit hanya
dapat dicapai dengan membangun budaya
yyangg berorientasikan kepada
p keselamatan
pasien
z Budaya y keselamatan p pasien harus dipahami,
p
dihayati dan diamalkan oleh seluruh unsur
rumah sakit
z Peran pimpinan, baik formil maupun non formil
diperlukan dalam membentuk nilai dan
memberi
b i tteladan.
l d