Lokakarya Patient Safety

Kongres XIII PERSI

Seminar Tahunan IX Patient Safety
Hospital Expo XXVIII
JCC, 21-24 Okt 2015

dr. Nico A. Lumenta, K.Nefro, MM, MHKes

Ketua Institut Keselamatan Pasien Rumah Sakit PERSI
 Fakultas Kedokteran
Univ Kristen Indonesia, 1970
Konsultan Nefrologi
Perhimpunan Nefrologi Indonesia, 1982
Magister Manajemen
Sekolah Tinggi Manajemen PPM
Jakarta, 1994
Lahir :
Magelang Magister Hukum Kesehatan
5 Nov 1943
Univ Katolik Soegijapranata Semarang,
2013
 Ketua Bidang Lit Bang Mutu Man Risiko
KARS th 2014-2018
Wakil Ketua Komite Keselamatan Pasien RS
Kem Kes th 2012-2015
Ketua Institut Keselamatan Pasien RS PERSI
(tahun 2005-2012 & th 2012-2015)
Advisory Council Asia Pacific, Joint
Commission International, sejak 2009
Kelompok Staf Medis Penyakit Dalam Ginjal
Hipertensi RS Mediros, Jakarta, sejak 1996
 Surveyor Komisi Akreditasi Rumah Sakit (KARS) sejak 1996
Konsilor KARS sejak 2012
PJ SubPokja Model Akreditasi Baru, Pokja
Penyempurnaan Akreditasi RS, DitJen Bina Yan Med,
DepKes, 2010-2011
Direktur Ketua RS PGI Cikini Jakarta 1983-1993
Dekan Fak Kedokteran UKI 1998-2001
Sekretaris Jenderal PERSI Pusat 19881990, 19901993,
19931996
Kepala Bagian Ilmu Penyakit Dalam FK-UKI, Jakarta, 1992
1995
Kepala Renal Unit (Unit Ginjal) RS.PGI Cikini, 1973 1981
 TataKelola Rumah Sakit dlm perspektif Std Akred 2012

PASIEN UU 44/2009 ttg

RS, Peraturan
Per UU an
Quality & Safety lainnya

Std Yan
Sistem Pelayanan Regulasi :

PCC
Kebijakan
Fokus Pasien Klinis Pedoman,
APK, HPK, Asuhan Pasien / Patient Care Panduan
AP, PP, SPO
PAB, MPO Program
PPK Indikator :
Sistem Ind. Area
Standar Manajemen Klinis
Manajemen Ind Klinis
PMKP, PPI, Ind SKP
TKP, MFK, Ind Upaya
KPS, MKI Manajemen
Sasaran KP
Sasaran Dokumen
MDGs Implementasi
 Good
Patient
PASIEN
Care
Tata Kelola
Asuhan Pasien
Quality & Safety
yang Baik

Good
Sistem Pelayanan
Clinical Klinis
Governance
Tata Kelola Klinis
Asuhan Pasien / Patient Care Good Hospital
yang Baik Governance &
Sistem Good Clinical
Good Governance
Hospital Manajemen
Ps 36 UU 44/2009
Governance
Tata Kelola RS
yang Baik Good Patient Care
Std Akreditasi RS 2012
 Pelayanan
Manajemen
Fokus Pasien
Risiko RS
(Patient Centered
Risiko Klinis
Care)

Safety is a
fundamental principle
Etik
of patient care and a
critical component of
Mutu Quality Management.
4 Fondasi Kebutuhan
Patient
PPA Asuhan pasien Pasien
Safety (World Alliance for Patient
Asuhan Medis
Safety, Forward Programme,
Asuhan Keperawatan
EBM WHO, 2004)
Asuhan Gizi
Asuhan Obat VBM Evidence Based Medicine
Value Based Medicine
KARS Dr.Nico Lumenta
(Nico A Lumenta & Adib A Yahya, 2012)
 Manajemen Risiko

Situational Awareness

Patient Safety
 Mengapa Keselamatan Pasien

100
Keselamatan
Pasien !

IpTek
PelayananMedis
Populasi
Menua
Risiko
Klinis ! 0
Waktu 1960 2000 +
Litigasi !
 PASIEN

Quality & Safety

Sistem Pelayanan
Klinis Nakes Pemberi Asuhan
Asuhan Pasien / Patient Care Pasien :
Dokter, Perawat,
Staf Klinis lainnya

Sistem Manajemen
Manajemen Pemilik
 Profesional
Pemberi Asuhan
DPJP
Perawat/
Bidan Apoteker

Psikologi Nurisionis
Klinis Dietisien

Terapis Teknisi Medis

Fisik Penata Anestesi

Profesional Pemberi Asuhan : Lainnya PPA

mereka yg secara langsung memberikan Tugas Mandiri,
asuhan kpd pasien, a.l. dokter, perawat, Tugas Kolaboratif,
bidan, ahli gizi, apoteker, psikolog klinis,
penata anestesi, terapis fisik dsb
KARS Dr.Nico Lumenta Tugas Delegatif
 Situational Awareness pada Konstruksi
What is situational awareness (SA) : Situational
awareness is being aware of what is happening
around you in terms of where you are, where
you are supposed to be, and whether anyone or
anything around you is a threat to your health
and safety.
Our knowledge, experience and education
enables us to understand what is going on
around us and helps us to determine if it is
safe. This means that everyones SA is
individual and potentially different. We use our
SA to make decisions and instruct others.
Our SA is only as accurate as our own
perception or reading of the situation, so what
we think is happening may not accurately
reflect reality. How we read a situation can be
influenced by many things such as the type of
information we have been given, our own
experience and distractions in the workplace.
(Leadership and worker involvement toolkit, www.hse.gov.uk/construction)
SA adalah keadaan sadar akan apa yg terjadi
di sekitar kita, tempat dimana kita berada,
dimana seharusnya kita berada, dan apakah
ada orang lain atau hal lain di sekitar kita
merupakan ancaman thd kesehatan serta
safety kita
Pengetahuan, pengalaman dan pendidikan
memampukan kita utk memahami apa yg
terjadi di sekitar kita dan membantu kita utk
menentukan apakah itu aman. Ini berarti bhw
SA setiap orang serta potensial berbeda. Kita
menggunakan SA untuk membuat keputusan
dan memerintah orang lain.
SA kita adalah sama akuratnya spt persepsi
atau kemampuan kita membaca situasi, jadi
apa yg kita pikirkan sdg terjadi tidaklah secara
akurat merefleksikan realitas. Bagaimana kita
membaca situasi bisa dipengaruhi banyak hal
spt tipe informasi yg kita terima, pengalaman
kita sendiri dan pengalihan perhatian di
tempat kerja
 Situational Awareness pada Konstruksi
Improve your situational awareness
Get in the habit of regularly pausing to make a quick mental assessment
of your working environment. When doing so, consider the following
questions:
Is there anything around you that poses a threat to your health and
safety and if so, to what extent?
Is the threat big enough that you should stop working?
Is there anything you can do to safely reduce that threat in order that
you can carry on working safely?
Jadikanlah kebiasaan untuk secara berkala / regular mengambil jeda
utk membuat asesmen mental secara cepat thd lingkungan kerja
anda, sambil mempertimbangkan pertanyaan2 berikut :
Adakah di sekitar anda potensi ancaman thd kesehatan dan safety
anda, serta berapa besarkah ancaman tsb?
Apakah ancaman itu begitu besar shg anda harus berhenti
bekerja?
Adakah yg dapat anda kerjakan untuk mengurangi ancaman itu
secara aman agar anda dapat bekerja seterusnya secara aman?
(Leadership and worker involvement toolkit, www.hse.gov.uk/construction)
 Situational Awareness pada Konstruksi
The SLAM Technique, consists of four simple steps:
STOP : Engage your mind before your hands. Look at the task in hand.
LOOK : at your workplace and find the hazards to you and your team mates. Report these
immediately to your supervisor.
ASSESS : the effects that the hazards have on you, the people you work with, equipment,
procedures, pressures and the environment. Ask yourself if you have the knowledge, training and
tools to do the task safely. Do this with your supervisor.
MANAGE : If you feel unsafe stop working. Tell your supervisor and workmates. Tell your
supervisor what actions you think are necessary to make the situation safe.

The SLAM Technique, terdiri dari 4 langkah sederhana :

STOP : Hubungkan pikiran anda tugas yg anda terima.
LOOK : perhatikan tempat kerja anda dan temukan bahaya yg mengancam
anda dan anggota tim anda. Laporkan segera kpd penyelia/supervisor anda
ASSESS : periksalah akibat2 dari bahaya2 itu thd anda, thd orang2, peralatan,
prosedur, tekanan2 dan lingkungan dalam hubungan dengan pekerjaan anda
MANAGE : Bila anda merasa tidak aman, berhentilah bekerja. Katakan kpd
supervisor dan teman2 kerja anda, tindakan2 apa yg anda pikir perlu diambil
utk membuat situasi aman

(Leadership and worker involvement toolkit, www.hse.gov.uk/construction)

Situational Awareness pada Penerbangan Sipil

Classes of Elements for Situational Awareness (SA)

Geographical SA : location of aircraft, airports, cities,
etc.
Spatial/Temporal SA : Altitude, heading, velocity, etc..
System SA : System status, transponder, ATC
communication, etc.
Environmental SA : Weather formations, etc.
Tactical SA : Flight dynamics, capabilities, etc.

(Garland, DJ et ala : Handbook of Aviation Human Factors, Mahwah, NJ, 1999)

 Situational Awareness in Healthcare
SA in Healthcare: A Vital Skill for Reducing
Medical Errors Today's Healthcare
Professional
SA has been studied and applied in military,
civil, commercial and aerospace applications
with great success. And because SA can help
decrease the likelihood that medical errors will
reach the patient, it is currently being taught in
medical team training sessions world-wide to
help improve patient safety
SA in healthcare is most often associated with
complex tasks and dynamic procedures, but
can be applied to everyday jobs in healthcare
from administration to nursing to the most
complicated and critical acute care settings
(Reducing Medical Error, Situational Awareness in Healthcare. www.saferhealthcare.com)
SA dlm pelayanan kesehatan adalah suatu
ketrampilan vital utk mengurangi Medical
Error para profesional pelayanan kesehatan
SA telah diteliti dan diterapkan di penerbangan
militer, sipil, komersial dan aplikasi aerospace
/ luar angkasa dengan sangat sukses. Karena
SA dapat membantu mengurangi
kemungkinan medical error menimpa pasien,
sekarang di seluruh dunia diajarkan dlm sesi
pelatihan tim medis, guna meningkatkan
patient safety
SA dalam pelayanan kesehatan paling sering
diasosiasikan/dihubungkan dengan tugas2 yg
kompleks dan prosedur yg dinamis, ttpi dapat
diaplikasikan/ diterapkan kpd pekerjaan
sehari-hari dlm layanan kesehatan dari mulai
administrasi smp keperawatan bahkan smp
asuhan akut dan kritis serta paling rumit
sekalipun
 Situational Awareness in Healthcare
SA in healthcare is a team responsibility. It
can't be achieved or maintained by just one
person. Each member of the team must be
empowered to speak up and participate in a
"SEE IT - SAY IT - FIX IT" approach
Effective team-based SA in healthcare
depends on team members sharing a common
knowledge base. In other words, all the actors
are working from the same script and share an
understanding of the mission and goals to be
accomplished
Using a "shared mental model" allows team
members to:
o Anticipate the needs of other team
members
o Predict the needs of other team members
o Adapt to task demands and changes
effectively
(Reducing Medical Error, Situational Awareness in Healthcare. www.saferhealthcare.com)
SA dlm yan kes adalah tang-jwb tim. Tidak dapat
dicapai atau dipertahankan hanya oleh satu
orang saja. Setiap anggota tim haruslah
diberdayakan untuk berani berbicara dan
berpartisipasi dgn pendekatan SEE IT SAY IT
FIX IT Lihat Katakan dan Perbaiki
SA yg efektif dalam yan kesehatan karena
team-based tergantung pd anggota2 tim yg
membagikan dasar pengetahuan yg sama. D.p.l.
semua pemeran bekerja dari script yg sama dan
membagikan suatu pemahaman dari misi dan
goal yg akan dicapai
Menggunakan shared mental model
memungkinkan para anggota tim utk :
o Mengantisipasi kebutuhan anggota tim yg lain
o Meramalkan kebutuhan anggota tim yg lain
o Menyesuaikan/mengadaptasikan pd tuntutan
tugas dan perubahan secara efektif
 Situational Awareness and Patient Safety
(Parush, A et al : SituationalAwareness and Patient Safety, The Royal College of Physicians and Surgeons of Canada, 2011.)

Simply put, Situational Awareness (SA) is
knowing what is going on around you
(Endsley, 2000).
When working with others, which is rather
common in various clinical contexts,
situational awareness includes having team
awareness, being aware of what team
members are doing (Pew, 1995).
But what is SA really? Is it knowledge that you
have? Some definitions suggest that it is an
abstraction that exists within our minds
(Billings, 1995; also, Endsley, 1988; Hamilton,
1987; and others).
Is it a process you go through? Many other
definitions suggest that it is to quickly detect,
integrate and interpret data gathered from the
environment (Green et al., 1995; also,
McMillan, 1994; Sarter & Woods, 1991; Smith &
Hancock, 1995; Vidulich, 1994; and others)
Secara sederhana, SA adalah mengetahui apa
yang terjadi di sekitar anda
Bila bekerja dengan orang lain, umumnya di
klinik, SA termasuk juga kesadaran tim, sadar
akan apa yang dikerjakan oleh anggota tim
Jadi apakah sesungguhnya SA ? Beberapa
definisi menunjukkan : suatu ringkasan yang
berada dalam pikiran kita.
Apakah Anda menjalani suatu proses? Banyak
definisi lain menyatakan : mendeteksi secara
cepat, mengintegrasikan dan menafsirkan data
yang dikumpulkan dari lingkungan
 Situational Awareness and Patient Safety
(Parush, A et al : SituationalAwareness and Patient Safety, The Royal College of Physicians and Surgeons of Canada, 2011.)
Is it an ability you possess? Yes, some
definitions suggest that SA is Ones ability to
remain aware of everything that is happening at
the same time and to integrate that sense of
awareness into what one is doing at the
moment (e.g., Haines & Flateau, 1992).
In the mid-1990s, when SA was still used and
trained almost exclusively in the aerospace
domain, an article on SA in anaesthesiology
was published in a special issue of the Human
Factors journal devoted to SA (Gaba & Howard,
1995).
15 years later, SA is thought to be one of the
most essential non-technical skills for the
achievement of safe anaesthesia practice
(Fioratou, Flin, Galvin & Patey, 2010).
SaferHealthcare, an international organization
specializing in providing training solutions to
healthcare, calls SA a vital skill for todays
healthcare professional.
Apakah itu suatu kemampuan yang ada pada
Anda? Kemampuan seseorang utk tetap sadar
ttg segala sesuatu yg berlangsung dlm waktu
yg bersamaan dan mengintegrasikan rasa
kesadaran itu menjadi apa yg diperbuat
seseorang pada saat itu
Pada pertengahan 1990-an, dimana SA masih
digunakan dan dilatihkan secara khusus dalam
bidang antariksa, suatu tulisan tentang SA
dalam anestesiologi dipublikasikan dalam
suatu terbitan khusus di jurnal Human Factors
yg diperuntukkan bagi SA.
15 tahun kemudian, SA dianggap sebagai salah
satu ketrampilan non-teknis yg paling penting
bagi pelaksanaan praktek anestesi yang aman
SaferHealthcare, Organisasi internasional yg
mengkhususkan diri dlm memberikan solusi
pelatihan yan kesehatan, menyebutkan SA
adalah suatu ketrampilan vital bagi para
professional yan kesehatan
 WHO Patient Safety
Definition : The safety culture of an organization
is the product of individual and group values,
attitudes, perceptions, competencies and
patterns of behaviour that determine the
commitment to, and the style and proficiency of,
an organisations health and safety
management.
Definition : Situation awareness refers to an
individuals perception of the elements in the
environment within the volume of time and
space, the comprehension of their meaning,
and the projection of their status in the near
future
SA is essentially what psychologists call
perception or attention. In essence, SA involves
continuously monitoring what is happening in
the task environment in order to understand
what is going on and what might happen in the
next minutes or hours (see Endsley & Garland,
2000).
Driving a car is a good example of a task that
requires a high level of SA.
Budaya safety dari suatu RS adalah suatu
produk dari nilai2, sifat, persepsi, kompetensi
dan pola perilaku individu dan kelompok, yang
menentukan komitmen terhadap, dan gaya
serta profisiensi / kemahiran dari, manajemen
kesehatan dan safety suatu organisasi
SA mengacu pada persepsi individu terhadap
elemen2 dalam lingkungan, sesuai dengan
waktu dan ruang, pemahaman terhadap makna,
dan proyeksi dari status mereka dalam waktu
mendatang
SA adalah penting sebagaimana para psikolog
menyebut sebagai persepsi atau atensi. Inti
sarinya adalah SA secara berkelanjutan
memonitor apa yang terjadi pada menit2 atau
jam-jam berikut
(Human Factors in Patient Safety Review of Topics and Tools : Report for
Methods and Measures Working, Group of WHO Patient Safety, WHO, 2009)
Human Factors in Patient Safety (WHO Patient Safety)
Basic description of major topic areas relating to human factors
relevant to patient safety 4 categories :

1. Organizational/ 1. Safety Culture

Managerial 2. Managers Leadership
3. Communication
2. Workgroup/Team 4. Teamwork - structure/
processes (dynamics)
5. Team leadership
(Supervisors)
3. Individual 6. Situation awareness
Cognitive (thinking) skills 7. Decision making
Personal resources 8. Stress
9. Fatigue
4. Work environment 10. Work environment
(Group of WHO Patient Safety : Report for Methods and Measures Working,
WHO Patient Safety, 2009)
 Human Factors in Patient Safety
(WHO Patient Safety)

Good SA is critical in all areas of healthcare, especially in acute

medicine when changes to the patients condition have to be
responded to promptly (e.g. anaesthesia, see Gaba et al 1995).
Surgeons place great store on SA, especially what they call
'anticipation', thinking ahead of the action about to be taken.
Way et al (2003) analysed 252 laparoscopic bile duct injuries and
found that the errors stemmed mainly from surgeons
misperception (i.e. poor SA) rather than problems in technical
skills.
SA and concentration are diminished by fatigue and stress and
can be affected by interruptions and distractions (common in
healthcare settings, see Healey et al, 2006).

(Human Factors in Patient Safety Review of Topics and Tools : Report for
Methods and Measures Working, Group of WHO Patient Safety, WHO, 2009)
 Human Factors in Patient Safety (WHO Patient Safety)

Situation Awareness and Patient Safety

According to Endsley (1995), there are 3 levels of SA and these can
easily be illustrated with examples, from healthcare :

1. What is going on? perception / persepsi

2. So what? comprehension / pemahaman
3. Now what? projection or anticipation / proyeksi
atau antisipasi

1. What is going on? The first level is perception which

involves noticing critical cues in the environment: e.g. the
patients vital signs, symptoms, monitor sounds.

Tingkat pertama adalah persepsi yang melibatkan perhatian

terhadap petunjuk/informasi yang ada di lingkungan: seperti
tanda2 vital & gejala2 pada pasien, bunyi2 monitor.
(Human Factors in Patient Safety Review of Topics and Tools : Report for
Methods and Measures Working, Group of WHO Patient Safety, WHO, 2009)
2. So what? The second level is comprehension i.e. what do
the cues mean in relation to this patient? For example, a nurse
has to combine information from the patient about reported
symptoms, readings from monitors and charts and other
nurses reports, to understand the status of a patients current
condition.

Tingkat kedua adalah pemahaman misalnya apakah arti

informasi/ petunjuk2 dalam hubungan dengan pasien? Misalnya,
seorang perawat harus menggabungkan informasi dari pasien
tentang gejala2 yang dilaporkan, informasi dari monitor dan grafik
serta laporan perawat2 lain, untuk memahami stasus dari kondisi
pasien terkini
3. Now what? The third level of SA is projection or anticipation.
This is a prediction of what will happen on the current task in
the near future. The nurse recognises a combination of
warning signs and realises that the patient is going to
deteriorate in the next few minutes and so takes action to
prevent this. This projection skill is critical in allowing for
proactive, rather than reactive response to both expected and
unexpected events (Wright & Endsley, 2008).

Tingkat ketiga dari SA proyeksi atau antisipasi. Ini adalah suatu

perkiraan apa yg akan terjadi pada tugas sekarang dalam waktu
berikut. Perawat mengenali suatu kombinasi antara tanda2
peringatan dan kesadaran bahwa pasien akan memburuk dalam
beberapa menit dan karenanya mengambil tindakan untuk
pencegahannya. Ketrampilan proyeksi adalah kritis agar bisa
proaktif, bukannya berespons secara reaktif terhadap kejadian yg
diharapkan dan yg tidak diharapkan.
 Human Factors in Patient Safety (WHO Patient Safety)

Situation Awareness and Patient Safety

Three distinct levels of SA (Endsley 1988) :

(Sinonim)
Level 1 SA : What is going Get Information
on? perception / persepsi Perception of the
elements in the
environment
Level 2 SA : So what? Understand the
comprehension / pemahaman Information
Comprehension of the
current status
Level 3 SA : Now what? Think Ahead
projection or anticipation / proyeksi Projection of the
atau antisipasi future status
(Human Factors in Patient Safety Review of Topics and Tools : Report for
Methods and Measures Working, Group of WHO Patient Safety, WHO, 2009)
 The Situational Awareness Checklist
1. Get Information Perception
Scan and search: be proactive about Jadilah proaktif dalam mendapatkan
getting the information. Dont wait until informasi. Jangan menunggu smp
the information is delivered to you. Look informasi itu diserahkan kpd Anda.
for it in your environment or solicit it Carilah informasi itu di lingkungan
from your team sekitar anda atau kumpulkan dari tim
anda
Pay attention: While attending and Sambil menjalankan dan berfokus pada
focusing on your own task, pay tugas anda sendiri, berikan perhatian
attention to what goes on around you. kepada apa yg terjadi di sekitar anda
Remain watchful: Even if everything Bahkan bila segala sesuatu berjalan dgn
proceeds smoothly and as planned, lancar dan sesuai rencana, tetaplah
remain watchful and expect the waspada dan selalu siap menghadapi yg
unexpected. tidak diharapkan
Communicate: You rarely work alone. Anda jarang bekerja sendiri.
Communicate with your team and peers, Berkomunikasilah dgn tim dan sejawat
even with the patient when relevant. anda, bahkan dgn pasien bila perlu
(Parush, A et al : SituationalAwareness and Patient Safety, The Royal College of Physicians and Surgeons of Canada, 2011.)
2. Understand the Information Comprehension
Compare: Compare the information to what
you know and what you expected. Are
things as planned? Or is the information
suggesting some variation or deviation from
what was planned or from the routine or
from your training and experience?
Critique: Think critically about the
information. As part of the critical thinking,
you should check information integrity
(accuracy, completeness, source, and
relevance), cross-reference it with additional
information, and assess conflicts and
contradictions.
Diagnose: Complete your understanding by
asking yourself: What does it mean? Why
did this happen or not happen?
(Parush, A et al : SituationalAwareness and Patient Safety, The Royal College of Physicians and Surgeons of Canada, 2011.)
Bandingkan informasi dgn apa yg anda
ketahui dan apa yg anda harapkan. Apakah
semua berjalan sebagaimana
direncanakan? Ataukah informasi mengarah
ke variasi atau devariasi dari apa yg telah
direncanakan atau dari rutin atau dari
pelatihan dan pengalaman anda
Berpikirlah kritis ttg informasi. Sbg bagian
dari berpikir kritis, anda harus mengecek
informasi dlm hal integritas (akurasi,
kelengkapan, sumber, dan relevansi),
bandingkan itu dgn informasi tambahan,
dan periksa konflik serta kontraindikasi yg
ada
Lengkapi pemahaman anda dgn bertanya
pada diri sendiri : Apa artinya itu? Mengapa
hal ini terjadi atau tidak terjadi?
3. Think Ahead Projection
Extrapolate and project: beyond the
now: How will the situation unfold if
the current conditions persist? Persist
for how long?
Ask what if? : Consider various
outcomes and contingencies and
communicate those possibilities to
others. Assess those possible
consequences so that they can drive
adequate decision making or initiate a
search for additional information and
the need to better understand that
information.
(Parush, A et al : SituationalAwareness and Patient Safety, The Royal College of Physicians and Surgeons of Canada, 2011.)
Buatlah ekstrapolasi dan proyeksikan :
diluar sekarang/saat ini : Bagaimana
situasi dibeberkan bila kondisi yg
sekarang masih bertahan? Bertahan
berapa lama?
Bertanyalah bagaimana jika :
Pertimbangkan berbagai hasil dan
kontingensi dan komunikasikanlah
kemungkinan2 itu kpd orang lain.
Carilah kemungkinan konsekuensi agar
dpt mendorong pembuatan keputusan
yg adekuat atau menginisiasi suatu
pencarian informasi tambahan maupun
kebutuhan utk lebih memahami
informasi tsb.
 SA Decision Action

Figure 1. Model of SA in dynamic

decision making (Endsley, 1995).

Endsley, MR : Situation Awareness Misconceptions and Misunderstandings, Journal

of Cognitive Engineering and Decision Making, Vol 9, Number 1, March 2015
 SA Decision Action

Figure 1. Model of SA in dynamic

decision making (Endsley, 1995).

Endsley, MR : Situation Awareness Misconceptions and Misunderstandings, Journal

of Cognitive Engineering and Decision Making, Vol 9, Number 1, March 2015
Figure 3. Higher level SA can be used to drive the search for data
and to provide default values when information is not available.

Endsley, MR : Situation Awareness Misconceptions and Misunderstandings, Journal of Cognitive

Engineering and Decision Making, Vol 9, Number 1, March 2015
Doctor-Patient Awareness Matrix
Dual Situation Awareness

(Olson, RA : Defining the Process of Medical Care to Include Dual Situation Awareness between
Patient and Clinician. Presentation, Habersham Medical Center, Demorest, Georgia)
 The Johari Window - 1955

Named after the first names of its inventors, Joseph Luft and Harry Ingham, this is one of
the most useful models describing the process of human interaction 1999 by Duen Hsi
Yen http://www.noogenesis.com/game_theory/johari/johari_window.html
(Olson, RA : Defining the Process of Medical Care to Include Dual Situation Awareness between
Patient and Clinician. Presentation, Habersham Medical Center, Demorest, Georgia)
Dr-Pt Situation Awareness
= SOAP

(Olson, RA : Defining the Process of Medical Care to Include Dual Situation Awareness between
Patient and Clinician. Presentation, Habersham Medical Center, Demorest, Georgia)
 A Case: Emergency Shoulder Reduction and
Procedural Sedation
1. Dr. Leblanc is near the end of his busy night shift in the emergency department. It is 7 A.M. and the
ED is overcrowded. Every bed is filled with patients. Dr. Leblanc has an hour to see as many of the
remaining patients as possible, complete evaluations of the house staff on shift, and prepare for
handovers to the day physician before he can get home.
2. He is also interrupted every two minutes with calls, inquiries from the nurses, residents looking to
discuss cases, and reviews of EKGs. The nurse reminds Dr. Leblanc that an elderly woman is still
waiting to reduce her dislocated shoulder. She had dislocated the shoulder 12 hours earlier but there
had been no bed overnight to perform the reduction.
3. The exhausted physician curses under his breath and walks over to the patients bed. With a
Respiratory Therapist (RT) present, Propofol is administered to the elderly woman to sedate her in
order to reduce her shoulder.
4. Upon starting the procedure a stroke code is called overhead. Dr. Leblanc sends the resident and
student to take care of the stroke code.
5. Turning to the patient to complete the procedure, Dr. Leblanc finds it is a particularly difficult
reduction.
6. Dr. Leblanc decides to pull harder on the arm, stopping briefly to administer more Propofol.
7. The reduction is so difficult that both the RT and nurse come to assist with countertraction. When
the shoulder is reduced an audible crack is heard. With frustration Dr. Leblanc curses and asks for
an x-ray to rule out a fracture.
8. When all present look up they realize the patient is not breathing and the monitor is flashing. The
audio alarms had been turned off.
9. The patient arrests and is resuscitated but subsequently dies in ICU.
1. Dr. Leblanc hampir usai shift malam-nya yg sibuk di IGD. Saat itu pk 7 pagi dan IGD dipadati
sangat banyak orang. Setiap TT sudah terisi pasien. Dr. Leblanc punya wkt 1 jam utk
memeriksa pasien2 yg menunggu, menyelesaikan evaluasi staf IGD yg bertugas shift itu,
dan menyiapkan handover / operan kepada Dr tugas siang sebelum pulang.
2. Dia juga diinterupsi setiap 2 menit dgn telpon, pertanyaan2 dari para perawat, residen yg
ingin mendiskusikan kasus2, serta mereview EKG. Perawat mengingatkan Dr. Leblanc bhw
seorang wanita tua masih menunggu utk tindakan thd dislokasi bahu. Dia mengalami
dislokasi bahu 12 jam sebelumnya tetapi tidak tersedia TT untuk melakukan reduction tsb.
3. Dr yg kelelahan menggerutu dan berjalan menuju TT pasien. Dengan hadirnya Respiratory
Therapist (RT), Propofol diberikan kpd wanita tua itu utk membiusnya agar dapat reduce her
shoulder.
4. Saat memulai prosedur, terdengar pengumuman stroke code. Dr. Leblanc mengirim
residen dan mahasiswa utk menangani stroke code tsb.
5. Kembali ke pasien utk menyelesaikan prosedur, Dr. Leblanc mendapati bahwa ini adalah
reduction yg cukup sulit.
6. Dr. Leblanc memutuskan utk menarik lengan dgn lebih kuat, berhenti sesaat utk
memberikan Propofol lagi.
7. Reduction ini begitu sulit hingga RT dan perawat datang dgn countertraction. Waktu
pelaksanaan tindakan, terdengar krekk. Dengan frustrasi Dr. Leblanc mengutuk dan
meminta dilakukan x-ray utk menepis adanya fraktur.
8. Semua yg hadir menengok dan sadar bahwa pasien tidak bernafas dan monitor berkelap-
kelip (flashing), krn alarm telah dimatikan.
9. Pasien berhenti dan diresusitasi tetapi kemudian meninggal di ICU
 Factors Affecting Loss of
Situation Awareness
Attention
attentional demands of controlled processes (k-based performance)
Pattern Recognition
inability to perceive pattern of cues (recognition-primed DM)
Workload
tasks too demanding or too many at once
Mental models
inadequate understanding of system or state
Working Memory
failure to adequately chunk information

Kass, S : Military Psychology, Situation Awareness.

Presentation, University of West Florida
 Situational Awareness in Healthcare

Beberapa tingkah laku mengindikasikan ketrampilan dalam SA :

Conducts frequent scan of the Sering melakukan pemindaian terhadap
environment lingkungan
Increases frequency of monitoring in Meningkatkan frekuensi monitoring sbg
response to patient condition respons thd kondisi pasien
Keeps ahead of the situation by giving Selalu lebih dulu dalam situasi saat
fluids/ drugs memberikan cairan / obat2an

Perilaku yg mengindikasikan ketrampilan dlm SA yg buruk pd seorang anestesiolog :

Does not respond to changes in patient Tidak merespon thd perubahan2 pada
state keadaan pasien
Responds to individual cues without Merespon tanda2 individual tanpa
confirmation konfirmasi
Does not consider potential problems Tidak mempertimbangkan masalah2 yg
associated with case potensial berhubungan dgn kasus

(Parush, A et al : SituationalAwareness and Patient Safety, The Royal College of Physicians and Surgeons of Canada, 2011.)
Improving Situation Awareness
Cue Filtering eliminate irrelevant cues
(clutter) that interfere with accurate
assessment of situation
Augmented Displays displays that
highlight or overlay actual information to
make it more salient
Spatial Organization arranging displays
to capitalize on spatial relationships (e.g.,
pop-out effect)
Automate Status Updates as the
environment changes the system should
warn the user of change
Train Users to Improve Attention?
mengurangi isyarat2 yg tidak relevan
(kekacauan) yg mengganggu akurasi
pemeriksaan situasi
contoh2 yang menyorot atau menutupi
informasi agar lebih menarik perhatian
mengatur contoh2 untuk memberikan
perhatian terhadap relasi spasial
(misalnya pop-out effect)
saat lingkungan berubah, sistem harus
memberi peringatan kepada pengguna
ttg perubahan tsb
Melatih pengguna/users untuk
meningkatkan perhatian ?
Kass, S : Military Psychology, Situation Awareness.
Presentation, University of West Florida
 Improving Situation Awareness
A fundamental concept of SA in Healthcare is
the "Red Flag.
A Red Flag indicates the loss of situational
awareness and generally means that
something is going wrong.
All team members should be alert to and
watch for red flags.
Some common red flags include:
o Feeling confused
o A gut feeling that something is wrong
o No one is watching or looking for hazards
o Using improper procedures
o Departing from established regulations
Red Flags tell us when SA in healthcare has
been lost or is being degraded.
You can also think of red flags as internal or
external stimuli that can degrade SA.
Suatu konsep fundamental dari SA dalam
pelayanan kesehatan adalah Red Flag
Suatu Red Flag mengindikasikan hilangnya SA
dan secara umum berarti bahwa ada
kesalahan sdg berlangsung
Semua anggota tim harus siaga terhadap dan
memperhatikan red flags
o Failing to meet planned targets
o Unresolved discrepancies
o Ambiguity
o Fixation or preoccupation
Red Flag memberitau kita bhw SA dlm yan kes
telah hilang/tergradasi.
Red flag juga berarti stimulus internal /
eksternal yg dpt men degradasi SA
Kass, S : Military Psychology, Situation Awareness.
Presentation, University of West Florida
 SA Medical Training
Gaba et als suggestions for training 1. Berikan latihan utk men-scan
SA in medical applications
1. Provide practice scanning
instruments and environment to
maximize perception of cues from
all relevant data streams
2. Provide explicit training in
allocation of attention using low
fidelity simulations, and multi-
faceted training in high fidelity
simulations
3. Provide enhanced training in
situation assessment and on
pattern matching of cues to known
disease and fault conditions
peralatan dan lingkungan utk
memaksimalkan persepsi dari
isyarat2 dari semua aliran data yg
relevan
2. Berikan pelatihan yg jelas dlm
mengalokasikan perhatian,
menggunakan simulasi yg
mendekati situasi sesungguhnya,
dan pelatihan dgn berbagai segi
masalah yg mendekati situasi
sesungguhnya
3. Berikan pelatihan pengayaan
(enhanced training) dalam situasi
asesmen dan pola yg sesuai dgn
isyarat2 penyakit yg dikenali
maupun kondisi2 yg keliru/salah
Kass, S : Military Psychology, Situation Awareness.
Presentation, University of West Florida
Situation Awareness Rating
Technique
Low High
1 2 3 4 5 6 7
Instability of Situation
Variability of Situation
Complexity of Situation
Arousal
Spare Mental Capacity
Concentration
Division of Attention
Information Quantity
Information Quality
Familiarity
Kass, S : Military Psychology, Situation Awareness.
Presentation, University of West Florida
 SA Summary
SA is the ability to step out, construct and maintain the big
picture
Several controllable factors can impact your ability to have it
and keep it
Understanding how these factors will come together (or came
together) can affect your ability to manage SA better in the
future

SA adalah kemampuan utk melangkah keluar,

mengkonstruksi dan menjaga gambaran besar
Beberapa faktor yg dapat dikendalikan dapat berdampak atas
kemampuan anda utk mendapatkan dan memilikinya
Memahami bagaimana faktor2 ini akan datang / terjadi
bersama2 (atau telah datang bersamaan) dapat
mempengaruhi kemampuan anda untuk mengelola SA yang
lebih baik di masa mendatang

(Situation Awareness and Decision Making in a Warning Environment,

Advanced Warning Operations Course)
Looks like one of the individuals is lacking SA in this domain
(Situation Awareness and Decision Making in a Warning Environment,
Advanced Warning Operations Course)
 dr. Nico A. Lumenta, K.Nefro, MM, MHKes
Institut Keselamatan Pasien RS

Terima kasih
atas perhatiannya

Journey to Quality and Safety