Anwar Wardy W

Center For Bioethics, Medicolegal and Humanities

Aspect.//HELP
FK.UMJ
anwar wardy w

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THE PATIENT SAFETY CURRICULUM

PATIENT SAFETY DOMAINS

KNOWLEDGE, SKILLS, ATTITUDES

1. Theoretical Foundations

Microsystems, historical trends, chaos, complexity, competency

and learning

2. Behavioral Aspects of Medical

Professionalism

Ethics, patient quality of life, resolution of conflict

3. Interpersonal Issues

Communication, stress and coping

4. Human Factors and

Ergonomics

Design history, error taxonomies, safety tools, decision support

systems, fatigue factors, user centered design

5. Systems Analysis

Usability criteria , organizations and learning disasters, place for

human error

6. QI Learning

Pareto/flow charts, and other QI tools, best practices, act cycles

7. Injury Epidemiology

Workplace hazards, worker safety, phases of injury, medico-legal

aspects

8. Medication Safety

Adverse and near-miss reporting, ISMP tools and website,

look/sound-alikes

9. Crisis Management Tools

Team work, shared decision making, situational awareness

10. Simulations

Micro-, macro-, debriefing, immersion levels, scripting, role

playing

Gilula,M.andBarachP.CreatingaPatientSafetyCurriculum:PurposiveSamplingofPatientSafetyExperts.79thClinical
anwar wardy w
center for help aspect,...fk.umj
andScientificIARSCongress.S143.Honolulu,Hawaii.March12,2005.;Gilula,Barach,2007.

Background on Patient
Safety and Patient
Safety Core Curriculum

anwar wardy w

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Mengapa Patient Safety

Quality

Structure

Quality

Process of care

Outcome

: AE

Costly

Cost: Invsment

Patient Safety
-Culture
-Reporting
-Learning/Analysis/Research
-K&R-based Standard-Guideline
-Implementasi,Monitor
-Patient Involvement
Kepercayaan meningkat
bioetika, makersi; fkk
Nicoumj
A. Lumenta/KKP-RS

Quality

Blaming
-Pengaduan, Tuntutan
-Tuduhan Malpraktek(Pid/Perd)
-Proses Hukum:Polisi,Pengadilan
-Blow-up Mass Media, 90%
Publikasi-opini negatif
-Pertahanan RS :
-Pengacara
-RS/Dr : Asuransi
-Tuntutan balik
- Dsb

Kecurigaan meningkat
anwar wardy w

KONSEP DASAR
PATIENT SAFETY

bioetika, makersi; fkk

umj

anwar wardy w

 Patient Safety adalah isu terkini, global, penting

(high
profile), dalam Pelayanan RS, praktis belum
lama, dimulai sejak Landmark Laporan IOM
th
2000.
WHO memulai Program Patient Safety th 2004 :
Safety is a fundamental principle of patient
care and
a critical component of quality management.
(World
Alliance for Patient Safety, Forward Programme WHO,2004)

KOMITE KESELAMATAN PASIEN RUMAH SAKIT

(KKPRS) dibentuk PERSI, pd tgl 1 Juni 2005
bioetika, makersi; fkk
umj

anwar wardy w
MENTERI KESEHATAN
bersama PERSI & KKP-RS

Patient Safety
negara

di

berbagai

1. Amerika : AHRQ (Agency for Healthcare

Research and
Quality), 2001
2. Australia : Australian Council for Safety and
Quality in
Health Care, 2000
3. Inggeris : NPSA (National Patient Safety
Agency), 2001
4. Canada : NSCPS (National Steering Committee
on
Patient Safety), CPSI (Canadian Patient Safety
Institute), 2003
5. Malaysia : Patient Safety Council, 2004
bioetika, makersi; fkk
anwar wardy
w
6.umjDenmark : UU Patient
Safety,
2003

The 93% vs. 7% Rule

Negligent
Conduct
(People)

Human
Error
(People)

Reckless
Conduct
(People)
anwar wardy w

Organizational
Design
93%

center for help aspect,...fk.umj

Knowing
Violations
(People)
8

Similar Vials: Atropine &

Phenylephrine

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Medication Cart Drawerdoes

Your Cart Look different?

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10

Microsystems Exist Within

Other Systems
Community,
Market, Social
Policy System

Patient Selfcare System

Macro
Organization
System

Individual
caregiver, team
and System

anwar wardy w

Clinical
Microsystem
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11

The TeamSTEPPS
Framework

Knowledge

Shared Mental Model

Attitudes

Mutual Trust
Team Orientation

Performance

Adaptability
Accuracy
Productivity
Efficiency
Safety

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Baker D, Salas E, Battles J, King H, Barach P, 2005, 2007

12

Adaptive and Reflective

Life-Long Learning
Simulations

Curriculum

Learning

Assess
Competence

Performing

Learning Portfolios
Yes

No

Knowledge Map
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13

Adverse Event Management

Plan
Containment Plan
Render care to pt
Staff Support
Contain risk of
harm/recurrence
Notification
Securing scene

Event

Activation

Crisis Mgt
Team

Investigation & RCA

Recovery
Monitoring
Restitution

Corrective Action
& Prevention

Communication Plan
Disclosure/
Patient
Organizational
External Audience
Recovery
Internal Audience
Notify Billing to hold bills
Immediate Response

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Follow-up Response

14

Elements of Organizational
Accidents
Task and
Environmental
Conditions

Individual
Unsafe Acts

Organizational
Processes
Failed Defenses

James T. Reason. The Human Factor in Medical Accidents. Medical Accidents.

anwar
wardy
Vincent
C,wEnnis

center
for helpUniversity
aspect,...fk.umj
M, and Audley
R. Oxford
Press 1993

15

Organizational Accident
Causation Model
Organization
Workplace

Person/team Defenses

Management
Decisions
&
Organisational
process

Accidents

Latent conditions pathway

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16

Elements of Organizational
Failure

Incompatible Goals
Organizational Structural Deficiency
Inadequate Communications
Poor Planning and Scheduling
Inadequate Control and Monitoring
Design Failures
Deficient Training
Inadequate Maintenance Management

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JT Reason 1993

17

Organization Accident
Causation Model
Organization

Workplace

Management
Decisions
&
Organisational
process

Error &
Violation
Producing
conditions

Person/team Defenses

Accidents

Latent conditions pathway

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18

Workplace Conditions
Promoting Unsafe Acts

High Workload
Inadequate Knowledge, Ability or
Experience
Inadequate Supervision or Instruction
Stressful Environment
Mental State
Change

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Work Environment
Violation Producing Conditions

Lack of Safety Culture

Management/Staff
Conflict
Poor Morale
Poor Supervision
Condones Violations
Misperception of
Hazard
Lack of Management
Concern

anwar wardy w

Little Pride in Work

Macho Culture
Bad outcomes
Wont Happen
Low Self-Esteem
License to Bend
Rules
Ambiguous or
Meaningless Rules

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20

Organizational Accident
Causation Model
Organization

Workplace

Management
Decisions
&
Organisational
process

Error &
Violation
Producing
conditions

Person/team Defenses

Errors &
violations

Accidents

Latent conditions pathway

anwar wardy w

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21

Person /Team
Individual Unsafe Acts

Errors
Attentional Slips and memory lapses (Intrusions,
omissions)
Mistakes
Rule based
Knowledge-based

Violations( deliberate deviation from regulation)

Routine ( shortcuts)
Optimizing Violations
Exceptional
Deliberate

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22

Organizational Accident
Causation Model
Organization

Workplace

Management
Decisions
&
Organisational
process

Error &
Violation
Producing
conditions

Person/team Defenses

Errors &
violations

Accidents

Latent conditions pathway

anwar wardy w

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23

Adverse Event Management

Plan
Containment Plan
Render care to pt
Staff Support
Contain risk of
harm/recurrence
Notification
Securing scene
Event

Activation

Crisis Mgt
Team

Investigation & RCA

Recovery
Monitoring
Restitution

Corrective Action
& Prevention

Communication Plan
Disclosure/
Patient
Organizational
External Audience
Recovery
Internal Audience
Notify Billing to hold bills
Immediate Response

anwar wardy w

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Follow-up Response

24

Risk Management
Support
Manage

family

contact with patient and/or

Coordinate

regulatory/accreditation
requirements

Managing

reputation risks

Media/Crisis communication
Internal and external

Managing

complaints and claims

Early non litiginous

settlement
center for help aspect,...fk.umj

anwar wardy w

25

Patient Safety Plan

High Reliability
Organization Culture/
Leadership

Identify
Failures

Patient
Centeredness
Knowledge
Sharing

Teamwork /
Human Factors
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Adapted from Kaiser Permanente

Manage
Failures

Reliable
Design
26

KEJADIAN YANG TIDAK

DIHARAPKAN (KTD)
DAN
PATIENT SAFETY

bioetika, makersi; fkk

umj

anwar wardy w

DATA KASUS DUGAAN MALPRAKTIK YANG SUDAH DILAPORKAN

Tgl
Lapor
1. 12 -02-04

Korban

Terlapor

Alm. Lucy Maywati

Kasus

RS Bersalin YPK Jkt Meninggal saat melahirkan caecar

Polda Metro Jaya
2. 23-04-04
Wulan Yulianti
RSCM Jkt
Meninggal krn operasi pd usus
Polda
Metro Jaya
3. 28 -04-04
Alm Lucy Maywati
RS Bersalin YPK Jkt Penggelapan M/R
Polda
Metro Jaya
4. 07-06-04
Jeremiah
RS Budi Lestari Bks Operasi caecar mengakibatkan
Polda
Metro Jaya
RS Hermina, Bekasi luka & cacat
5. 11 -06-04
Mindo Sihombing
RS Persahabatan Jkt Gagal operasi hernia
Polda
Metro Jaya
6. 15-06-04
Anissa Safitri
RSCM Jkt
Hidrocepalus
Polda
Metro Jaya
7. 24 -06-04
Alm. Jajang
RSUD Sukabumi Jabar
Wabah malaria di Sukabumi
Polda
Jawa Barat
8. 30-06-04
Alm. Lucy Maywati
RS Bersalin YPK Jkt Meninggal saat melahirkan
Polda Metro Jaya
9. 07 -07-04
Robinson L. Tobing
RS Kodam Bkt Barisan
Vegetativ State akibat
operasi/
Polda Sumatra
Medan
cacat permanen
Utara
10. 12-07-04
Anissa Safitri
Yayasan Amal Beduli Perbuatan tdk menyenangkan
Polda Metro
Jaya
Seribu, Jkt
krn memulangkan pasien
11. 08 -07-04 Ngatmi
RS Persahabatan Jkt Operasi kanker payudara
Polda
Metro Jaya
12. 14-07-04
Rohati
RS Darmais Jkt
Meninggal dunia akibat gagal
Polda
Metro Jaya
operasi kanker payudara
13. 18 -07-04 Dr Jane P
PT Newmont Minahasa
Pencemaran limbah B3
Mabes Polri
Raya, Sulawesi Utara
14. 18-07-04
Srifika Modeong
RS CM & RS MMC Jkt Keracunan mercury & arsen
Mabes Polri
makersi;
fkk Rahman RS CM & RS MMC Jkt Keracunan mercury & arsen
15.bioetika,
18 -07-04
Rasyid
Mabes Polri
anwar wardy w
umj
16. 18-07-04
Juhria RatubaheRS CM & RS MMC Jkt Keracunan Mercury & arsen
Mabes Polri

17. 18 -07-04

Masna Stiman

RS CM & RS MMC Jkt Keracunan mercury & arsen

18. 26-07-04

Revy Anastasia RS Cikini Jkt

Keracunan Obat

Mabes Polri
Polda Metro

Jaya
Revy Anastasia Apotik RS Cikini Jkt Keracunan Obat
Polda Metro
Jaya
20. 12-08-04
Rasyid Rahman Menkes Ahmad Sujudi
Pencemaran nama baik dgn
Mabes Polri
Mentamben P Yusgiantoro menyatakan tdk ada pencemaran
Men LH Nabiel Makarim
21. 18 -08-04 Fellina Azzahra RS Karya Medika Jkt Meninggal krn salah operasi usus
Polda
Metro Jaya
22. 31-08-04
Again Isna Nauli
RS Islam Bogor
Kelalaian medis yg berakibat
SATGA OPS Polda
cacat permanen
Jawa Barat
23. 03 -09-04 Anggi & Anggeli
RSCM Jkt
Membiarkan pasien yg hrs dirawat
Polda Metro Jaya
24. 03-09-04
Andreas
RS Pasar Rebo Jkt
Kelahiran yg mengakibatkan cacat
Polda
Metro Jaya
25. 03 -09-04 Maena Nurrocmah
RS Setia Mitra Jkt
Operasi usus
Polda
Metro Jaya
26. 15-09-04
Fellina Azzahra RS K Medika Cibitung
Meninggal krn operasi usus
Polda
Metro Jaya
RSCM Jkt
27. 16-09-04 Leonardus W Pete
RS Silom Gleaneglas Penyaderaan krn tdk mampu byr
Polda Metro Jaya
28. 27-09-04 Wino
Polres Sorong Papua Penganiayaan mengakibatkan
Mabers Polri
Wiran
mata dan dada rusak parah
19. 09 -07-04

29. 28-09-04

Lexyano Hamsalim

RS Medistra Jkt
Infeksi akibat operasi klip jantung
Polda Metro Jaya
30. 28-09-04 Parrel Davin H.A RS Eva Sari
Lalai mengakibtakan org lain
Polda Metro
Jaya
Sinurat
Rawamangun Jkt
meninggal
31. 05-10-04 Rizka Hudha
RS Harapan Bunda Jkt
Lalai mengakibatkan kematian
Polda
Metro Jaya
32. 05-10-04 Masita Ariani
Klinik Bedah Plastik Kegagalan bedah plastik pd hidung
Dit
Reskrim Polda
(Annisa)
Bandung
Jawa Barat
bioetika,
makersi; fkk
33. 07-10-04
Tyava Putra Juliarty
Klinik Dharma Bakti 2
Keracunan obat
anwar wardy
w
umj
mengakibatkan
Polda
Metro Jaya
RS harapan Kita Jkt Steven Johnson Syndrom

34. 20-10-04

Chealfiro M.P

RSCM Jkt

Operasi Hemia

Polda Metro

Jaya
Pencemaran nama baik
Polda
Metro Jaya
36. 06-11-04 Fatimah
RSCM Jkt
Kelalaian mengakibatkan kematian
Polda Metro Jaya
37. 10-11-04 Panca Satriya
Dr. Siti Fadillah S
Dugaan tindak pidana membuat
Mabes Polri
Hasan Kesuma
(Menkes RI)
perasaan tdk menyenangkan
38. 14-01-05 Siti Zulaeha
RSUD Pasar Rebo Jkt Kesalahan dlm operasi
Polda
Metro Jaya
39. 16-02-05 Selli Wane Carolina
RS Fatmawati Jkt
Kesalahan dlm operasi pd tulang
Polda Metro Jaya
belakang berakibat cacat
40. 24-02-05 Martha Manulang
RS St Carolus Jkt
Salah obat
Polda Metro Jaya
41. 11-03-05 Chris
RS Sumber Waras Jkt
Kesalahan dlm operasi
Polda Metro Jaya
RS Mitra Kemayoran Jkt
42. 11-03-05 Tumi
RS Harun Jkt
Kesalahan dlm operasi
Polda
Metro Jaya
43. 11-03-05 Erwin Said
dr. GW Sp.B
Pelaku tanpa seizin korban
SIAGA OPS
mengambil ginjal korban
Bandar
Lampung
44. 12-05-05 Royke Bagalutu, SH
Rosyid Rusdi
Melarang membawa anak ke
SATGAS OPS Jabar
Sandino Brata
RS Hasan Sadikin Bandung
(Asisten I Sukabumi)
45. 26-05-05 Royke Bagalatu, SH PT BIO FARMA Indo
Pemberian vaksin polio yg tdk
SATGAS OPS Jabar
diakui WHO
46. 12-06-05 Nabila
Ka Dinkes Jabar
Anaknya kejang2, panas berak2
Polda Metro Jaya
Dinkes Depok
setelah imunisasi polio, kmd
Menkes RI
meninggal
PT Bio Farma Indonesia
47. 18 -06-05 Wagirin
RS Pelabuhan
Kelalaian Medis
Polda
Metro Jaya
bioetika,
makersi; fkk
BUHAROYAN
NADAPDAP
Sumber : Dari berbagai sumber
anwar wardy w
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35. 20-10-04

Sahat Parulian

SH

RS Cikini Jkt

Microsystems Exist Within

Other Systems
Community,
Market, Social
Policy System

Patient Selfcare System

Macro
Organization
System

Individual
caregiver, team
and System

anwar wardy w

Clinical
Microsystem
center for help aspect,...fk.umj

31

Vertical Alignment
Safest Hospital

Vision
(Aim)
Mission &
Objectives

Policy & Programs

Right information, right place,

right time
Team based training

Tactics
Expectations

anwar wardy w

Zero incidence of harm

Behaviors

Communicate clearly
Safety KSAs

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32

PENERAPAN
KESELAMATAN PASIEN
RUMAH SAKIT
1). TUJUH LANGKAH MENUJU
KESELAMATAN PASIEN RUMAH SAKIT
2).

STANDAR KESELAMATAN PASIEN

RUMAH SAKIT
bioetika, makersi; fkk
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anwar wardy w

KKP-RS NO 001-VIII-2005

TUJUH LANGKAH
MENUJU
KESELAMATAN
PASIEN RUMAH
SAKIT
PANDUAN BAGI STAF RUMAH SAKIT

(KKP-RS)
bioetika, makersi; fkk
umj

anwar wardy w

7 LANGKAH
BANGUN KESADARAN AKAN NILAI KP, Ciptakan
kepemimpinan & budaya yg terbuka & adil.
PIMPIN DAN DUKUNG STAF ANDA, Bangunlah komitmen
& fokus yang kuat & jelas tentang KP di RS Anda
INTEGRASIKAN AKTIVITAS PENGELOLAAN RISIKO,
Kembangkan sistem & proses pengelolaan risiko, serta
lakukan identifikasi & asesmen hal yang potensial bermasalah
KEMBANGKAN SISTEM PELAPORAN, Pastikan staf Anda
agar dgn mudah dapat melaporkan kejadian / insiden, serta
RS mengatur pelaporan kpd KKP-RS.
LIBATKAN DAN BERKOMUNIKASI DENGAN PASIEN,
Kembangkan cara-cara komunikasi yg terbuka dgn pasien
BELAJAR & BERBAGI PENGALAMAN TTG KP, Dorong
staf anda utk melakukan analisis akar masalah untuk belajar
bagaimana & mengapa kejadian itu timbul
CEGAH CEDERA MELALUI IMPLEMENTASI SISTEM KP,
Gunakan informasi yang ada tentang kejadian / masalah untuk
melakukan
bioetika,
makersi; fkk perubahan pada sistem pelayanan
KKP RS
anwar wardy w
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GETTING
STARTED
Self-assessment

Alignment with organizational strategy

Program Infrastructure
Inventory of current patient safety
activities
Resource allocation
Capacity

Results
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36

SAFETY PROGRAM
Linkage with
Leadership/Organizational Culture
Oversight responsibility/infrastructure
Stakeholder Engagement
Work Plan Development
Execution Model(s)
Monitoring/Measurement
Participation/accountability
Spread/Sustainability

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37

Whats on the Horizon for

Patient Safety?
The

role of the built environment

Patient centered processes
Smart automation
Adaptive informatics
Focus on the team and simulation
Full disclosure
Telemedicine/remote care
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38

KNOWLEDGE & SKILL SET

Leadership/Negotiation

Principles
Human Factors Engineering
Behavioral Science Principles
Systems Thinking and Complexity Theory
Performance Improvement
Project Management
Change Management
Patient Safety Language Literacy
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39

THE PATIENT SAFETY CURRICULUM

Patient Safety Domains

Knowledge, Skills, Attitudes

1. Theoretical Foundations

Microsystems, historical trends, chaos, complexity, competency and

learning

2. Behavioral Aspects of
Medical Professionalism

Ethics, patient quality of life, resolution of conflict

3. Interpersonal Issues

Communication, stress and coping

4. Human Factors and

Ergonomics

Design history, error taxonomies, safety tools, decision support

systems, fatigue factors, user centered design

5. Systems Analysis

Usability criteria , organizations and learning disasters, place for

human error

6. QI Learning

Pareto/flow charts, and other QI tools, best practices, act cycles

7. Injury Epidemiology

Workplace hazards, worker safety, phases of injury, medico-legal

aspects

8. Medication Safety

Adverse and near-miss reporting, ISMP tools and website,

look/sound-alikes

9. Crisis Management Tools

Team work, shared decision making, situational awareness

10. Simulations

Micro-, macro-, debriefing, immersion levels, scripting, role playing

Gilula,M.andBarachP.CreatingaPatientSafetyCurriculum:PurposiveSamplingofPatientSafetyExperts.79thClinical
anwar wardy w
center for help aspect,...fk.umj
andScientificIARSCongress.S143.Honolulu,Hawaii.March12,2005.;Gilula,Barach,2007.

40

Rules for Health Care

Design in
the 21st Century
Current Approach
New Approach
Do no harm is an
individual
responsibility
Information is a
record
Secrecy is necessary
The system reacts to
needs
Professional
autonomy drives
variability

anwar wardy w IOM.

Safety is a system
property
Knowledge is shared
and information
flows freely
Transparency is
necessary
Needs are
anticipated
Decision making is
evidence-based

Crossing the Quality

National Academy Press, 2001.
center forChasm.
help aspect,...fk.umj

41

References

Advanced Training Program, Intermountain

Healthcare, Salt Lake City.
http://intermountainhealthcare.org/xp/public/institute/cours
es/atp/#objectives

Leadership Guide to Patient Safety from

the Institute for Healthcare Improvement
at http://www.ihi.org

The University of Michigan Healthsystem

Patient Safety Toolkit at
http://www.med.umich.edu/patientsafetytoo
lkit/
anwar
wardy w
center for help aspect,...fk.umj
42

Cantor M, Barach P, Derse A, et al. JCAHO

2005;31:5-13.
Kramam SS, Hamm G. Ann Intern Med
1999;131:963-967.
Clinton H, Obama B. NEJM 2006.
Gallagher T, et al. NEJM 2007.
http://www.sorryworks.net
Risk Management Pearls on Disclosure of
Adverse Events. American Society for
Healthcare Risk Management at
http://www.ashrm.org

anwar wardy w

center for help aspect,...fk.umj

43