Plan Of Action

Tindak Lanjut Moc Survey

Standar Focus Pasien
 1. IPSG
No Temuan Kegiatan PIC Dead Line
Penyelesaia
n
1 Safety Of High-Alert Medication (Goal 3) :

a. Policy and Practice lacks clarity on storage of Policy Penyimpanan, AA. 24 Agustus
elektrolit konsentrasi tinggi (NaCl dan SPO pencampuran Karsana 2012
MgSO4) sesuai dgn signa
b. KCl konsentrasi tinggi tersimpan tdk aman di SPO AA. 24 Agustus
unit pelayanan dan di Farmasi Karsana 2012
c. Kesenjangan indikasi klinis untuk SPO AA. 24 Agstus
penyimpanan elektrolit konsentrasi di tinggi Karsana 2012
diluar farmasi (Pasien perlu pemberian
elektrolit konsentrasi tinggi dalam waktu < 30
mnt sdgkan farmasi blm bisa memenuhi)
d. Kesenjangan bukti ilmiah pembuatan daftar SK jenis high alert AA. 24 Agustus
obat high alert (Obat pelumpuh otot tdk Karsana 2012
masuk dalam daftar high alert)
e. Pemberian kode berwarna untuk obat obatan Implementasi AA. 24 Agustus
LASA hanya digunakan di Farmasi (multiple lapangan (SPO) Karsana 2012
streng dan LASA)
 1. IPSG
No Temuan Kegiatan PIC Dead Line
Penyelesaian
2 Benar tempat, benar prosedur dan benar pasien operasi :

a. Pre-operative verification list does not address Revisi form Dr. 24 Agustus
all required documents Sudartana 2012
b. Tissue grafting dan dental site marking belum Daftar Kebijakan prosedur Dr. 24 Agustus
dimasukkan dlm kebijakan presedur risiko tinggi risiko tinggi Sudartana 2012
yg memerlukan time out process dan site
marking
c. Time out check list does not address all required Revisi blanko time out Dr. 24 Agustus
elements Sudartana 2012
3 Reduce the Risk of Health Care Aquired Infection (HCAIs) (Goal 5)

a. Hand hygiene tdk patuh (tdk konsisten) terhadap Sosialisasi Dr. 24 Agustus
ketentuan (petunjuk yg ada) sudartana 2012
4 Reduce Risk of Patient Harm Resulting From Falls (Goal 6)

a. Inconsistent documentation of use of required Dr. 24 Agustus

falls risk assessement tools Sudartana 2012
b. Assessment tools does not allow for adequate Revisi form Guna 24 Agustus
assessement of patients risk for falling Hariati 2012
c. Bathrooms too far for access by patients and SPO pasien obgyn ke kamar W. Suardika 24 Agustus
distance might contribute to risk for falling mandi 2012
2. Access to Care and Continuity (ACC)
No Temuan Kegiatan PIC Dead Line
Penyelesaian
5. Reduction of barrier to access and delivery of services (ACC 1.3)

a. Barrier not yet listed or fully difined (form kajian awal : bhs, tuli, Kebijakan Dr. Anom 24 Agustus
miskin), pelayanan pada pasien khusus 2012
b. Effort to limit barriers not yet organized or fully implemented Sosialisasi Dr. Anom 24 Agustus
2012
6. Delays for diagnostic and/or treatment services (1.1.3)

a. No Policy and practice does on informing patients of reason for Kebjakan dr. Anom S 24 Agustus
delay in care and treatment 2012
b. Policy is unclear regarding appropiate level of care when a lengthy Kebiajakan dr. Anom S 24 Agustus
delay in treatment is anticipated lanjut 2012
7. Qualified individual responsible for patient care during all phase of care and treatment (ACC 2.1)

a. Unclear of this process is implemented (Penjelasan rencana Case Aries 24 Agustus

tindakan) manager Minarti 2012

8. Policy Regarding process for patient to leave hospital on approved pass (ACC 3)

a. Lack a requirement to attemp to contack the patient after the Resume dan dr. Anom S 24 Agustus
defined period of absence is exeeded (Resume pasien yg dirawat , discharge 2012
termasuk di poli ada resume) plan blanko
2. Access to Care and Continuity (ACC)
No Temuan Kegiatan PIC Dead Line
Penyelesaia
n
9. Summary list for out Patient (ACC 3.3)

a. Not maintained and no listing of require SPO (resume pasien poli Dr. Anom S 24 Agustus
issues yg sering datang) 2012
10. Transfer of Patient to other organizations

a. Not determined if other organization SPO Dr. Anom S 24 Agustus

can meet the need of the patient being 2012
transfer (ACC.4.1)
b. Clinical summary not transfered with Sosialisasi form transfer Dr. Anom S 24 Agustus
the patient (ACC 4.2) (hal 58) pasien, ada komunikasi 2012
kesiapan RS yg terima dan
dicatat (hal 58)
c. Incomplete document information (ACC Pembuatan documen, Dr. Anom S 24 Agustus
4.4) (hal 59) sosilaissi 2012
 3. Patient and Family Rights (PFR)
No Temuan Kegiatan PIC Dead Line
Penyelesaian
11. Patient Privacy (PFR 1.2)

a. Lack of privacy and confidentiality for patient in some Lengkapi fisik Ngurah 24 Agustus
multi-bed units Sukadarma 2012
b. Patient expectations of privacy not determined SPO Dr. Surya N 24 Agustus
2012
12. Confidentiality of patient information (PFR 1.6)

a. Patient information discussed in front of unautorized SPO Dr. Surya N 24 Agustus

individuals 2012
13. Witholding of resuscitative services (PFR 2.3)

a. DNR orders do not consistently contain patient or Sosilaisasi, monev Dr. Surya N 24 Agustus
family consent 2012
14. Patient Rights and responsibilities (PFR 5)

a. Not available in other frequently encountered Revisi hak dan kewajiban Dr. Surya N 24 Agustus
languages menjadi 2 bahasa 2012
b. Not routinely given to in patients or newly registered Sosilaisasi dan Tracer 24 Agustus
outpatient monitoring pengampu 2012
15. Informed Consent (PFR 6.4.1)

a. Incomplete list of procedure requiring informed Informed consent Dr. Surya N 24 Agustus
consent tindakan sedasi, 2012
sosilaisasi
b. Consent for reuse of dializer signed in dialysis, but Sosilaisasi, Monev Tracer 24 Agustus
incomplete for all information pengampu 2012
 4. Assessment of patient (AOP)
No Temuan Kegiatan PIC Dead Line
Penyelesaian
16. Initial Assessment (AOP 1.2)

a. Generaly do not include initial phychological Revisi blanko, Sosilaisasi, Dr. Nila 24 Agustus
assessment based on patient needs Monev 2012
b. Fall and skin risk assessments not consistently Revisi blanko, sosialisasi, Dr. 24 agustus
performed (and forms not available and/or not monev Sudartana + 2012
adequate to assess risk) Alit
17. Assessment less than 30 days old (AOP 1.4.1)

a. Policy does not specify the required process SK , SOP Dr. Nila 24 Agustus
2012
18. Nutritional and functional screening at time of initial assessment (AOP 1.6)

a. Not Consistently evident Sosialisasi Dr. Nila 24 Ags 2012

19. Pain assessment (AOP 1.7)

a. Not consistently documented, and times of SPO, sosialisasi Dr. Nila + 24 Ags 2012
assessement not generally evident Aries
b. Not pain management program yet identified for SPO, sosialissi Dr. Cok 24 Ags 2012
maternity patiens Senapati+Ai
ries
20 Specialized initial assessments (AOP 1.8)

a. Written criteria not present, though stated on some Kebijakan umum AOP Dr. Nila 24 Agustus
assessment forms (ass pasien kelompok khusus) (hal 2012
b. Some special needs populations not identified (i.e SPO Dr. Nila 24 Agustus
Psych patients) 2012
 4. Assessment of patient (AOP)
No Temuan Kegiatan PIC Dead Line
Penyelesaia
n
21. Initial assessment includes need for discharge planning (AOP 1.11)

a. Not documented in review records SPO revisi Dr. Nila+Dr Anom 24 Ags 2012

22. Reassessments (AOP 2)

a. Pain reassessments not consistently documented after treatment SPO pain revisi, Dr. Cok Senapati + 24 Agustus
sosialisasi Aries 2012
23. Laboratory Services

a. Lab Waste not safely discarded (AOP 5.1), kebijakan pembuangan limbah SPO Gek Utik + Arnata 24 Ags 2012
harus satu, tiap unit buat SPO (PPI)
b. All blood culture collection bottles and most specimen collection tubes SOP tatacara Dr. Dewa Sukrama, 24 Ags 2012
expired in obstetric ward (AOP 5.4) pengamprahan dan Dewa Parwata
distribusi tabung.
Monev dan Ganti
c. Written guidelines do not include monitoring of temprature for Kebijakan monitoring Gek Utik 24 Ags 2012
refrigerated reagents (AOP 5.5) suhu kulkas tempat
reagen.
d. No written procedure regarding the ordering, transport, storage, and Evaluasi / revisi SPO Gek Utik, Dewa 24 Ags 2012
preservation of specimens (AOP 5.6) Buat satu pedoman ketiga parwata
laboratorium.
24. Radiation Safety Program (AOP 6.2)

a. Policies unclear re oversight and testing of lead aprons and dosimeter Revisi kebijakan Dr. Margiani, Sindu 24 Ags 2012
radiation badges (berapa apron dicek, siapa yg, jadwalnya)
b. Handling and disposal of infectious and hazardous materials for Urus izin incenerator Ngh Sumerta 24 Ags 2012
destruction in incenerator might be pose additional risk to the
environment
 5. Care Of Patient (COP)
No Temuan Kegiatan PIC Dead Line
Penyelesaian
25. Care Delivery for all patients (COP 1.0)

a. Uniform care policy does not address all issues in Revisi kebijakan Umum Dr. Purwa 24 Ags 2012
intent statement
b. Lack of uniform practice of providing privacy curtains Lengkapi korden Ngurah 24 Ags 2012
or screens in multiple patient care unit Sukadarma
26. Care Plan (COP 2.1)

a. Inconsistent documentation of integrated care plans Soslialisasi Dr. Purwa 24 Ags 2012

b. Lack of measurable goals (form pengkajian awal dan Lengkapi Care Plan (SPO) Dr. Purwa + 24 Ags 2012
integrasi) Dr. Nila
27. Care Of High Risk Patients and provission of high risk services

a. Lack of policy (COP 3.1) SOP pasien emergency Dr. Purwa 24 Ags 2012

b. Policy does not address abused patients (COP 3.8) SOP bila ada kesalahan Dr. Purwa 24 Ags 2012
perawatan
28. Care Of Patient in Dialysis (COP 3.6)

a. Reusable dialyzer stored incorectly in numbered bins Cocokkan daftar dgn yg Dr. Jodi S 24 Ags 2012
that do not match the listings in dialysis unit tersimpan (SPO)
b. Filter changes for reverse osmosis (R/O) not recorded Catat penggantian filter Dr. Jodi S 4 Ags 2012
(SPO)
 5. Care Of Patient (COP)
Nost Temuan Kegiatan PIC Dead Line
af Penyelesaian
29. Food and Nutrition Therapy (COP 4.0)

a. Food order not ducumented by autorized staff Implementasikan untuk Rina M 24 Ags 2012
mencatat kebutuhan
manaknan oleh petugas
gizi
b. Storage of food on patient care units without control Buat SPO penyimpanan Rina M, 24 Ags 2012
measures to assure safe storage makanan di ruang Dewa
perawatan Parwata
30. Pain Management (COP 6)

a. Stroke patient with pain did not receive pain therapy Sosilaisasi Ngurah 24 Ags 2012
14 hours after physician order Sukadarma
b. Not evident that patients and families are educated Sosialisasi SPO edukasi Dr. Surya 24 Ags 2012
about pain lengkapi
c. Pain not consistently treated as per pain Sosialisasi, SPO nyeri Dr. Cok 24 Ags 2012
management guidelines, and time of treatments not revisi Senapati
documened to indicate if treatment provided in a
timely manner
 6. (ASC)Anesthesia and Surgical Care

No Temuan Kegiatan PIC Dead Line

Penyelesaian
31. Sedation Care (ASC 3)

a. Sedation policy does not address all requirements in Revisi SPO sedasi Dr. Alek 24 Ags 2012
intent statement and does not address methods
specific to pediatric population
b. General anesthesia form used for sedation consent Revisi informed consent Dr. Alek 24 Ags 2012
does not address sedation risks and benefits anestesi
 7. Medication Management and Use (MMU)
No Temuan Kegiatan PIC Dead Line
Penyelesaian
32. Organization and Management (MMU 1)

a. Lack of process to inform clinical staf of required SPO obat baru 24 Ags 2012
informaiton on new drugs added to formulary
33. Storage (MMU 2.1)

a. Keys left in locked medication cubicles and doors SPO penyimpanan 24 Ags 2012

34. Emergency medications (MMU 3.2)

a. Dificulty in locating keys limits timely access to Pakai segel saja 24 Ags 2012
emergency cart medication drawer
b. Policy for inspecting emergency cart not consistently Sosialisasi 24 Ags 2012
followed
35. Expired Medications (MMU 3.3)

a. Open multiple dose vials not properly labeled with SPO obat multi dosis 24 Ags 2012
erquired expiration date (21 hari dari sat dibuka)
35. Ordering and Transcribing (MMU 4.0)

a. Current medication lists inconsistently documented Sosialisasi, lengkapi 24 Ags 2012

and not available to pharmacists
b. Current list not consistently used as reference for Sosialisasi 24 Ags 2012
determining admission orders
 7. Medication Management and Use (MMU)
No Temuan Kegiatan PIC Dead Line
Penyelesaian
36. Ordering and Transribing (MMU 4.1)

a. Policy does not address all requirements in intent Revisi Kebijakan Dr. Sindu 24 Ags 2012
statement
b. All required elements of order inconsistently Blanko order supaya bisa 24 Ags 2012
documented dibuat dlm billing
c. Lack of standardized method for writing and verifying Buat Standar 24 Ags 2012
accuracy of body surface area order for
chemotherapy
37. Preparation (MMU 5.0)

a. Chemotherapy prepared in non ventilated hood on Buat SPO AA. Karsana 24 Ags 2012
clinical units by untrained nursing staff
b. Use of non ventilated hoods in pharmacy prevents Pengadaan ventilated AA. Karsana 24 Ags 2012
sterile preparation of intravenous medications hoods
38. Appropriatness Review (MMU 5.1)

a. Required patient-specific information inconsistently Revisi order form AA. Karsana 24 Ags 2012
documented on order forms provided to pharmacy
b. Reviews not done for chemotherapy and other SPO review AA. Karsana 24 Ags 2012
medications dispensed but not prepared in pharmasi
 7. Medication Management and Use (MMU)

No Temuan Kegiatan PIC Dead Line

Penyelesaian
39. Preparing and dispensing (MMU 5.2)

a. Ready-to-administer medications dispensed from Label sama untuk pasien Wyn Nurata 28 Ags 2012
pharmacy not consistently labeled with two patient pakai barcode (Nama
indentifiers dan No CM)
b. Syringes with propofol not labeled in operating Buat label propofol inj AA. Karsana 28 Ags 2012
theaters

40. Monitoring (MMU 7.1)

a. Lack of Clear definition for medication error and near Perbaiki definisi AA. Karsana 28 Ags 2012
miss events medication error dan
near miss
b. Lack of accurate reporting and data analysis methode Perbaiki laporan dan AA. Karsana 28 Ags 2012
analisis data
 8. Patient and Family Education (PFE)
No Temuan Kegiatan PIC Dead Line
Penyelesaian
41. Patients and families ability and willingness to learn (PFE 2.1)

a. Form does not indicate assessment of family needs Revisi form Dr. Surya 28 Ags 2012

42. Education Provided to patients and family (PFE 3)

a. Education not consistently documented Sosilaisasi Dr. Surya 28 Ags 2012

43. Effectiveness of patient learning (PFE 5)

a. No evidence of verification of understanding by Buatkan metode Dr. Surya 28 Ags 2012

patients and families of education provided verifikasi
44. Collaborative process for education not evident (PFE 6) Buat model edukasi Dr. Surya 28 Ags 2012
colaboratif