Pelatihan Pencegahan dan Pengendalian Infeksi Rumah Sakit dan Fanyankes Lainnya

PERSI, 26-29 November 2013

PERAN PENCEGAHAN DAN

PENGENDALIAN INFEKSI
DALAM PATIENT SAFETY

Santoso Soeroso
HEALTH TECHNOLOGY ASSESMENT PERSI
IMRS PERSI
Jakarta
The Institute of Medicine in 1999 issued a
report called “To Err is Human” that stated
that as many as 98,000 people die annually as
a result of medical errors.
Medical errors seriously harm one in every
10 patients around the world.

Pencanangan Gerakan Keselamatan Pasien

Oleh Menkes , Jakarta, 21 Agustus 2005

"…Safe care is not an option. It is the right

of every patient who entrusts their care to
our Healthcare systems …”
“ Patient safety is now recognized by health
systems around the world,“
Sir Liam Donaldson,
Chair, WHO World Alliance for Patient
Safety, 2 May 2007
 Patient safety : All about system

Technology Organization
and Tools

Patient Outcomes

PROCESSES:
Person * care process
* other processes

Individual &
Organizational
Tasks Outcomes
Environment

“The majority of safety problems in patient care are explained by a failure in communication and information management”
 Patient safety : Why error ?

Situational Latent Active Failure

Factors Failure (Human Factors)

SAFETY BARRIERS

• Humans are “set up” to make errors that they are not responsible for
• Most errors result from faulty systems rather than human error
 The ‘Swiss cheese’ model
DEFENCES
Procedures
Physical barriers
Information
THE GAPS
Decisions

Poor protocols

Faulty equipment

Missing information

Patient
Inadequate supervision
harmed
Adapted from Professor James Reason
Confusing drug names is one of the most common causes of
medication errors and is a worldwide concern. With tens of
thousands of drugs currently on the market, the potential for
error created by confusing brand or generic drug names and
packaging is significant. The recommendations focus on using
protocols to reduce risks and ensuring prescription legibility or the
use of preprinted orders or electronic prescribing.
 The widespread and continuing failures to correctly identify
patients often leads to medication, transfusion and testing errors;
wrong person procedures; and the discharge of infants to the
wrong families. The recommendations place emphasis on methods for
verifying patient identity, including patient involvement in this process;
standardization of identification methods across hospitals in a health
care system; and patient participation in this confirmation; and use of
protocols for distinguishing the identity of patients with the same name.
Gaps in hand-over (or hand-off) communication between patient
care units, and between and among care teams, can cause
serious breakdowns in the continuity of care, inappropriate
treatment, and potential harm for the patient. The
recommendations for improving patient hand-overs include using
protocols for communicating critical information; providing
opportunities for practitioners to ask and resolve questions during
the hand-over; and involving patients and families in the hand-over
process.
 Considered totally preventable, cases of wrong procedure or
wrong site surgery are largely the result of miscommunication and
unavailable, or incorrect, information. A major contributing factor
to these types of errors is the lack of a standardized preoperative
process. The recommendations to prevent these types of errors rely on
the conduct of a preoperative verification process; marking of the
operative site by the practitioner who will do the procedure; and having
the team involved in the procedure take a “time out” immediately before
starting the procedure to confirm patient identity, procedure, and
operative site.
 While all drugs, biologics, vaccines and contrast media
have a defined risk profile, concentrated electrolyte
solutions that are used for injection are especially
dangerous. The recommendations address standardization of
the dosing, units of measure and terminology; and prevention
of mix-ups of specific concentrated electrolyte solutions.
 Medication errors occur most commonly at transitions. Medication
reconciliation is a process designed to prevent medication errors at
patient transition points. The recommendations address creation of the
most complete and accurate list of all medications the patient is currently
taking—also called the “home” medication list; comparison of the list against
the admission, transfer and/or discharge orders when writing medication
orders; and communication of the list to the next provider of care whenever
the patient is transferred or discharged.
The design of tubing, catheters, and syringes currently in use
is such that it is possible to inadvertently cause patient harm
through connecting the wrong syringes and tubing and then
delivering medication or fluids through an unintended wrong
route. The recommendations address the need for meticulous
attention to detail when administering medications and feedings
(i.e., the right route of administration), and when connecting
devices to patients (i.e., using the right connection/tubing).
 One of the biggest global concerns is the spread of Human
Immunodeficiency Virus (HIV), the Hepatitis B Virus (HBV), and
the Hepatitis C Virus (HCV) because of the reuse of injection
needles. The recommendations address the need for prohibitions on
the reuse of needles at health care facilities; periodic training of
practitioners and other health care workers regarding infection control
principles; education of patients and families regarding transmission of
blood borne pathogens; and safe needle disposal practices.
 It is estimated that at any one time, more than 1.4 million
people worldwide are suffering from infections acquired in
hospitals. Health care-associated infections (HAI) occur
worldwide and affect both developed and developing
countries. In developed countries, between 5% and 10% of
patients acquire one or more infections and 15%–40% of patients
admitted to critical care are thought to be affected.
In resource-poor settings, rates of infection can exceed 20%,
available data are scanty and more research is needed
to assess the burden of disease in developing and transitional
countries.
 Faktor Kontribusi Penyebab IKP IKP=Setiap kejadian atau
situasi yang dapat
mengakibatkan atau
Insiden Keselamatan Pasien berpotensi mengakibatkan
harm (penyakit, cedera,
cacad, kematian dll) yang
Hasil / Dampak tidak seharusnya terjadi.
pd Pasien

KTD=Kejadian Tidak Diharapkan Cedera (Adverse Event)

KNC=Kejadian Nyaris Cedera
Tidak cedera (Near
Miss)

Proses Analisis
(Unpreventable) (Preventable)
KTD Tidak dpt dicegah KTD / KNC Dpt dicegah
Forseeable - unavoidable, Medical Error, Medical
Acceptable, Unforseeable – Negligence,dsb
risk, dsb
 Faktor Kontribusi

1. Work Environment Factors,

2. Patient Factors,
3. Organizational Factors,
4. Human and Performance Factors,
5. External Factors.

Penyebab IKP

1.Care Planning, 2.Care Process Design, 3.Communication,

4.Continuum of Care, 5.Human Factors, 6.Information
Management, 7.Organization Culture, 8.Patient Assessment,
9.Patient Identification, 10.Patient Involvement and
Education, 11.Physical Resources
KejadianTidak Diharapkan (KTD)(Adverse event)

Suatu kejadian yg mengakibatkan cedera yg tdk diharapkan pada

pasien karena suatu tindakan (commission) / tidak bertindak
(omission), ketimbang krn underlying disease atau kondisi pasien.

Kejadian Nyaris Cedera (KNC) (Near miss)

Suatu kesalahan akibat melaksanakan tindakan (commission)

atau tdk mengambil tindakan yg seharusnya diambil (omission),
yg dpt mencederai pasien, tetapi cedera serius tidak terjadi.
1. Mendapat obat “c.i.”, tidak timbul akibat apapun (chance)
2. Dosis lethal akan diberikan, diketahui, dibatalkan (prevention)
3. Mendapat obat “c.i.”/dosis lethal, diketahui, diberi antidote
(mitigation).
 Insiden Keselamatan Pasien
IKP
IKP dgn dampak langsung IKP akibat st kondisi
pd pasien laten (Latent error)
1.Clinical Management, 1. Infrastructure
2. Documentation & Communication 2. Resources
3.Healthcare Associated Infection
4.Agents
5.Patient Behaviour
6.Abscondence / Missing / Left
Against Medical Advice
7.Patient Accident
8. Patient abuse
JCI : 1.Anesthesia events, 2.Behavioral events, 3.Criminal events, 4.Environment-
related events, 5.Equipment-related events, 6.Infection-related events,
7.Medication errors, 8.Medical events, 9.Obstetrical events, 10.Pediatric events,
11.Surgical events, 12.Transfer/discharge-related events, 13.Other unanticipated Events.
 Kategori Insiden (KKPRS, 2007)
 1.Pengelolaan klinis
 2.Dokumentasi
 3.Pemeriksaan penunjang diagnostik
 4.Komunikasi
 5.Infeksi nosokomial
 6.Pemberian obat
 7.Pemberian transfusi
 8.Perilaku pasien
 9.Kecelakaan/patient accidents
 10.Alat medis
 11.Infrastruktur
 12.Sumber daya
 Kategori insiden pada Laporan Insiden Keselamatan Pasien/IKP
(Incident Report)
Menurut KKPRS,2007
No Kategori insiden Komponen Subkomponen
.
1 PENGELOLAAN KLINIS Misassessment

Misdiagnosis

Salah tatalaksana Terlambat,

Persiapan tdk adekuat,
Gagall
mengontrol,misjudgement,
tindakan tdk sesuai
prosedur, tidakan diluar
kewenangan, salah bagian
yang dioperasi

Gagal monitoring Terlambat,gagal,tidak

memonitor,
perpanjangan LOS

Penghentian
asuhan yang tidak
patut/abandonment
 Contoh Incident Report
Incident Report Form

 Form ini digunakan untuk semua insiden (klinis dan non klinis). Jika lebih dari satu
orang terlibat dalam insiden yang sama, form yang terpisah harus dibuat untuk masing-
masing individu. Segera selamatkan korban, amankan lokasi, dan lakukan pertolongan
jika diperlukan; serta lakukan pencegahan agar tidak terjadi cedera pada yang lainnya.

 Segera lengkapi form ini dan harus sudah diserahkan kepada Risk Management Officer
selambat-lambatnya dalam waktu 48 jam setelah insiden terjadi.
 Hari / Tanggal Kejadian : Jam : (Gunakan sistem penulisan waktu 24 jam)
 Lokasi kejadian : Gedung/Area/Lantai: Ruang (Tulislah sedetail mungkin):
 Nama korban (Tulislah selengkap mungkin) : Pasien Pengunjung Petugas Lain-lain
 Alamat Korban (Diisi jika korban bukan pasien):
 Kerusakan Properti :MedisNon MedisNama Properti: Jenis
Kerusakan: Identitas Properti (Tulislah sedetail mungkin):
 Nama saksi (Orang pertama yang mengetahui kejadian): Pasien Pengunjung
Petugas Lain-lain
 Deskripsi singkat apa yang terjadi (Mohon dicatat juga dalam rekam medik. bila
diperlukan / Ingat! Hanya informasi yang objektif atau fakta ):
 Safety Assessment Codes (SAC)
Matrix Looks
Severity Categories

Probability Minor (no Moderate Major (permanent Catastrophic

incr.LOS/<$ (increase lessening/ >$100.00) (death or permanent loss
10.000) LOS/>$10.000 but < of functions)
$100.000)

Frequent (several 2 2 3 3
times in 1 year)

Occasional 1 2 3 3
(several times in 1 – 2
years)

Uncommon 1 1 2 3
(sometime in 2 – 5 years)

Remote (sometime 1 1 2 2
in 5 – 30 years)
 Probability Categories
Frequent – Likely to occur immediately or within a short
period (may happen several times in 1 year).

Occasional – Probably will occur (may happen several

times in 1 to 2 years).

Uncommon – Possible to occur (may happen sometime in

2 to 5 years).

Remote – Unlikely to occur (may happen sometime in 5 to

30 years).
 Severity Categories
Catastrophic
Patients with Actual or Potential:
Death or major permanent loss of function (sensory, motor,
physiologic, or intellectual)not related to the natural course of the
patient's illness or underlying condition (i.e., acts of commission or
omission). This includes outcomes that are a direct resultof injuries
sustained in a fall; or associated with an unauthorized departure from
an around-the-clock treatment setting; or the resultof an assault or
other crime.
Or any of the following:
 Suicide (inpatient or outpatient)
 Rape
 Hemolytic transfusion reaction
 Surgery or procedure on the wrong patient or wrong body
part
 Infant abduction or infant discharge to the wrong family
Visitors: A death; or hospitalization of 3 or more visitors
Staff : A death or hospitalization of 3 or more staff*
Fire: Any fire that grows larger than an incipient stage‡
Moderate
Patients with Actual or Potential: Increased length of stay or
increased level of care for 1 or 2 patients
Visitors: Evaluation and treatment for 1 or 2 visitors (less than
hospitalization)
Staff : Medical expenses, lost time or restricted duty injuries or illness
for 1 or 2 staff
Equipment or facility: Damage more than $10,000 but less than
$100,000** , ♦
Fire – Incipient stage or smaller‡
Major
Patients with Actual or Potential:
Permanent lessening of bodily functioning (sensory, motor,
physiologic, or intellectual)not related to the natural course
of the patie nt's illness or underlying conditions (i.e., acts of
commission or omission) or any of the following:
 Disfigurement
 Surgical intervention required
 Increased length of stay for 3 or more patients
 Increased level of care for 3 or more patients
Visitors: Hospitalization of 1 or 2 visitors
Staff: Hospitalization of 1 or 2 staff or 3 or more staff
experiencing lost time or restricted duty injuries or illnesses
Equipment or facility: Damage equal to or more than
$100,000** , ♦
Minor
Patients with Actual or Potential: No injury, nor increased
length of stay nor increased level of care
Visitors: Evaluated and no treatment required or refused
treatment
Staff: First aid treatment only with no lost time, nor restricted
duty injuries nor illnesses
Equipment or facility: Damage less than $10,000 or loss of
any utilitywithout adverse patient outcome (e.g., power, natural
gas, electricity, water, communications, transport, heat and/or
air conditioning)**, ♦
Angka Kejadian yang tidak diharapkankan menurut
hasil studi menggunakan data Rekam Medik

NEGARA JUMLAH KTD (%) CACAT

REKAM MEDIK PERMANEN +
KEMATIAN(%)
Australia 14,179 10.6 2.0

Amerika 14,565 10.0 2.0

Kanada 3,745 7,5 1,6

Denmark 1,097 9.0 0.4

Inggris 1,014 11.7 1.5

New zealand 6,579 12.9 1.9

Sumber : Runciman et al : Safety and Ethics in Healthcare, 2007

 Sentinel events menurut catatan resmi
Sentinel events = unexpected occurrence involving death, serious physical/psychological injury
and the risk thereof. (Joint Commission Resources, 2001)

Type of adverse events USA (%) of 1579 AUSTRALIA (%) of

cases 175 cases
Suicide of in-patient 29 13

Surgery wrong part/wrong 29 47

person
Medication error lead to 23 7
death
Incompatible blood 6 1
transfusion
Maternal death 3 12

Retained instrument 1 0

Sumber : Runciman et al : Safety and Ethics in Healthcare, 2007

 Fundamental part of safety culture
 Staff are open about incidents they have been
involved
 Staff and organization are accountable for their
actions
 Staff feel able to talk to their colleagues and
superiors about any incident
 Staff are treated equally and fairly and supported
whenever incident happens
 Stanford Patient Safety Centre inquiry
culture survey
 Senior management commitment and attitude toward
patient safety
 How risk are perceived among different staff
 How safety data is handled
 Whether staff stick to policies and procedures
 How well safety resourced and the training staff
received
 The quality of communication in team
 Whether reporting incident is rewarded or punished
 Patient Safety dalam kinerja komponen
organisasi ( Behal, R , 2004)
 Komponen individual :
a) Task requirements and individual skills,
b) individual needs and values,
c) work unit climate, motivation
 Komponen transaksional :
a) Structures : Patient safety team, infection control team, peer review
b) Systems : CPOE, event reporting tool, incentive, policies & procedure for
reporting and disclosure
c) Managerial practices : Training, monitoring, implementation, recognition
 Komponen transformasional :
a) Leadership : Vision, direction, communication, role models
b) Mission and Strategy : Mission Statement, Strategic Plan
c) Organization culture : Self reporting, near miss reporting, new staff
indoctrination
 7 Area pembelajaran
 1) Berkomunikasi secara efektif : open disclosure, informed
consent
 2) Identifikasi, mencegah, menangani KTDdan KNC :
managing risks, managing complaints
 3) Memanfaatkan bukti dan informasi : using IT to enhance
safety
 4) Bekerja dengan aman : Understanding human factors, complex
organization, managing fatique and stress
 5) Berperilaku etis
 6) Pembelajaran terus menerus
 7) issue spesifik : medicating safely, preventing wrong site, wrong
procedure, wrong patient
 Patient safety : Infection Control Nurse

 Anggota aktif Tim Keselamatan pasien, Tim Infeksi

nosokomial
 Root Cause Analysis, Audit Medik, Audit klinik
 Menggunakan data outcome untuk menilai tingkat
keberhasilan
 Professional self regulation, Perbaikan kinerja
 PIRAMIDA INFEKSI

Septicaemia

Spreading invasive
infection
Local infection/critical colo
nisation

Colonisation
Dg atau tanpa
Gejala klinis
Contamination
 Lingkungan Rumah Sakit

Daerah Kamar Operasi / Daerah Semi-Publik

Aseptik-1

Aseptik-0

Aseptik-2
Kamar Bedah (DaerahAseptik)

Daerah sekitar Kamar Operasi/Daerah Publik

Skema Dasar Pembagian Daerah Sekitar Kamar Operasi

Model Lay-out of Operating Room No.1

EQUIPMENT LIST
1 50,000 LUX МОВILЕ EMERGENCY LIGHT W/BACKUP ВАТТR.
2 TECHNICAL WALL FOR OPERATING ТНЕАТRЕ.
3 MUlTIPURPOSE MEDICAL ЕХАМ.& TREATMENT TROLLEY INCLUDING
RESUSCETATION UNIT FОR ADULT/СНILD/INFANT, ECG WITH PORTABLE
DEFIBRILLATOR AND MAJOR 5 РАВАМЕТЕRS MONITORING SУSТЕМ.
4 INFUSI0N STAND
5 SURGICAL SUTURES TROLLEY
6 KIDNEY DISH W/STAND.
7 КIСК BUCKET САRТ DN САSТОRS
8 UNIVRSAL OPERATING ТАВLЕ.
9 CEIlING SUSPENDED МАJOR OPERATING LIGHT.
10 SURGICAL INSTRUMENTS ТАВLЕ. GLАSS TOP.ON CASTORS
11 МАУО TROLLEY FOR OPERATING ТНЕАТRЕ
12 MONITORING SYSTEM-MODULAR РАRАМЕTЕRS- ON TROLLEY
13 LINEN НАМРЕR
14 SURGICAL INSTRUMENTS TROLLEY W/SНELVES AND DRAWERS.
15 SURGICAL DIATHERMY,CAUTERY ANO COAGULATION..
17 MOBILE UNNERSAL АNАЕSTНЕSIА UNIT W/VENTILATOR
18 2-JARS EMERGENCY SUCTION UNIT ON CASTORS
19 MOBILE UNIVERSAL ANAESTHESIA UNIT W/RESPERAT0R/VENTILATOR.
20 Х-RАУ FILM VIEWER (SINGLE, DOUBLE OR TRIPLE)
23 НОРРЕR
24 SURGEON STOOL W/CHESTREST
27 WORKING ВЕNСН W/LOWER CАBINETS & DRAWERS
32 STORING SHELVES AND РАCKS FOR MULTIPURPOSE STORAGE
33 SCRUB-UP.
34 DISINFECTANT LIQUID SOAP DISPENSER FOR HAND WASH
51 MULTI PURP0SE STORING CABINET
6O EMERGENCY DERBRILLATOR/РАСЕМАКЕ~ MOBIlE UNIT.
116 SERVICE PENDANT IN ОР.ТН. FOR POWER S0CKETS, MEDICAL GASES,
AND SCAVENGING SYSTEM OUTLET.
117 MOBIIE SURGICAL SUCTI0N UNIT ON CASTORS.
118 SURGICAL LASER UNIT ( CARBON DIOXIDE )
121 BACTERIACIDE LАМР
INFEKSI SALURAN NAFAS
HUMIDIFIER DAN NEBULIZER SBG SUMBER
PENULARAN HAI
Staphylococcus aureus biofilm
28
Resistensi antibiotika
 AUDIT
 Terminologi audit mencakup sejumlah aktivitas
yang berkisar antara penilaian diri yang tidak
terstruktur (unstructured self assessment) sampai
review komprehensif yang terkait struktur ,
proses dan dampak.
 Dalam kaitan keselamatan pasien (patient safety)
suatu audit berarti review independen terhadap
kejadian , temuan kasus, evaluasi, klasifikasi
dengan menggunakan kriteria tertentu
Sub-judul yang disarankan pada SOP
 Definisi
 Tujuan
 Kebijakan
 Pertimbangan Patient Safety
 Peralatan
 Persiapan
 Prosedur
 Dokumentasi
 Referensi
 Identifikasi Risiko
Identifikasi Risiko adalah suatu proses
melakukan identifikasi semua situasi atau
kejadian yang menimbulkan potensi perlukaan,
penyakit atau kerugian finansial. .

Pada semua SOP baik Klinik maupun Non-

klinik, semua risiko harus dikenali dan diperiksa.
Kemudian koreksi dilakukan untuk mengurangi
timbulnya risiko
 Contoh Risiko

 Sampel darah diberi label secara ceroboh

 Diagnosis salah
 Pengendalian Infeksi di rumah sakit buruk
 Kerusakan peralatan medik
 Kehilangan daya listrik dan ketidak mampuan generator untuk
melakukan back-up daya listrik
 Staf melakukan tindakan yang bukan wewenangnya atau sama
sekali belum pernah diajarkan shg menimbulkan KTD/KNC.
 Identifikasi Pasien

 Lakukan pengecekan gelang pasien (identaband)

terkait nama lengkap, tanggal lahir, No, MR,
sesuai Medical Record, Medication chart, permintaan
Radiology , Lab , Informed consent dsb.
 Jika pasien berada di poliklinik , pasien diminta
menyebutkan nama dan tanggal lahir dan hal itu
kemudian dicek pada biodata yang ada pada MR
 Mengurangi Risiko melalui SOP
 Apakah praktik yang sekarang dilakukan adalah praktik berbasis
bukti dengan melihat referensi SOP :

 Menggunakan Penelitian yang dipublikasi melalui peer

reviewed journals ( New England Journal of Medicine , Critical
Care Medicine dsb.) atau Cochrane Library yang diterbitkan
paling tua 5 tahun yang lalu. Buku teks boleh juga digunakan
namun tahun penerbitannya hendaknya tidak lebih dari 2
tahun lalu.
 Menggunakan Clinical guidelines yang dikeluarkan oleh Badan
yang berwenang dan memiliki kompetensi misalnya :
National Guidelines Clearinghouse US-CDC :
http:/www.guideline.gov/summary/summary.aspx?ss=15&d
oc id=4253&nbr=3253
4. CLINICAL RISK MANAGEMENT

 CRM is about identifying what goes wrong in patient care

and why, and learning lessons from these events to ensure action
is taken to prevent reccurences

 CRM meminimalkan risiko dengan cara :

1. Menjamin tim benar benar trampil
2. Menjamin anggota tim waspada dan paham
terhadap peran dan tanggungjawabnya
3. Menjamin lingkungan kerja aman dan bebas
dari kekurangan