03. PS is a Key Component of RM (Dr.adib 2012)
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Transcript of 03. PS is a Key Component of RM (Dr.adib 2012)
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CURRICULUM VITAEDATA PRIBADI
Nama : dr.ADIB ABDULLAH YAHYA,MARSPangkat : Brigjen TNI (Purn)Tempat/tanggal lahir : Magelang,16 Februari 1949
Jabatan : President Asian Hospital Federation (AHF)Agama : IslamALAMAT : Jl. Punai H-24,Kel.Tengah,Jakarta Timur – 13540
Telp : (021)8404580Fax : (021) 8408047
HP : 08161803497 E-MAIL : [email protected]
PENDIDIKAN UMUM
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PENDIDIKAN UMUM
SMA Negeri Magelang 1966S1 : Fakultas Kedokteran Universitas Gajah Mada (UGM),
Yogyakarta, 1973S2 : Fakultas Kesehatan Masyarakat, Universitas Indonesia (UI), Jakarta,
Program Kajian Administrasi Rumah Sakit ( KARS )
PENDIDIKAN MILITER
Sekolah Staf dan Komando TNI Angkatan Darat (SESKOAD), 1987/1988
PELATIHAN
Combined Humanitarian Assistance Response Training, oleh Singapore Armed Forces (SAF), Singapura, 2000Health as a Bridge for Peace Workshop, oleh World Health Organization (WHO), Yogyakarta, 2000
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PENGALAMAN JABATANKomandan Detasemen Kesehatan Pasukan Pengamanan Presiden (DanDenkes Paspampres), 1987-1991Kepala Rumah Sakit “Muhammad Ridwan Meuraksa”, Jakarta, 1992Kepala Kesehatan Daerah Militer (Kakesdam) Jaya, Jakarta, 1993Komandan Pusat Pendidikan Kesehatan TNI – AD,1995 – 1999Wakil Kepala Pusat Kesehatan TNI, 1999 – 2000Kepala RSPAD Gatot Soebroto, 2000 – 2002Dekan Fakultas Kedokteran UPN, Jakarta, 2000 – 2002Wakil Ketua Tim Dokter Kepresidenan RI, 2000 – 2002Direktur Kesehatan TNI Angkatan Darat (Dirkesad), 2002-2004Wakil Ketua Tim Pemeriksaan kesehatan untuk calon Presiden dan calon Wakil Presiden RI Th.2004DOSEN Pasca Sarjana FKM UI, Kajian Administrasi Rumah Sakit (KARS)
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DOSEN Pasca Sarjana FKM UI, Kajian Administrasi Rumah Sakit (KARS)DIREKTUR UTAMA RUMAH SAKIT MMC
ORGANISASIKetua Ikatan Rumah Sakit Jakarta Metropolitan (IRSJAM), 2000-2003Ketua Umum Perhimpunan Rumah Sakit Seluruh Indonesia ( PERSI), 2003-2009Anggota Komnas FBPI. Ketua Komtap Bidang Kebijakan Kesehatan KADIN IndonesiaAngggota TNP2K.Ketua Divisi Kemahkamahan Majelis Kehormatan Etik Kedokteran (MKEK) IDI Pusat Tim Konsultan Institut Manajemen Risiko Klinis ( IMRK )Koordinator Bidang 1 : KAJIAN KESELAMATAN PASIEN, KKPRSInstruktur HOPE ( Hospital Preparedness for Emergencies and Disasters}PRESIDENT OF ASIAN HOSPITAL FEDERATION ( AHF ) 2009 – 2011
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PATIENT SAFETY IS A KEY COMPONENT OF PATIENT SAFETY IS A KEY COMPONENT OF RISK MANAGEMENTRISK MANAGEMENT
Dr. ADIB A YAHYA, MARSPRESIDENT
ASIAN HOSPITAL FEDERATION( AHF )
WORKSHOP KESELAMATAN PASIEN DAN MANAJEMEN RISIKO KLINIS DI RUMAH SAKIT
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1. What?
3. How?
44
2. Why?
3. How?
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What ?What ?
55
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DEFINISI RISIKODEFINISI RISIKO
RISIKO ADALAHRISIKO ADALAH ::
“ “ POTENSI TERJADINYA KERUGIANPOTENSI TERJADINYA KERUGIANYANG DAPAT TIMBUL DARI PROSESYANG DAPAT TIMBUL DARI PROSES
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YANG DAPAT TIMBUL DARI PROSESYANG DAPAT TIMBUL DARI PROSESKEGIATAN SAATKEGIATAN SAAT SEKARANGSEKARANG ATAUATAUKEJADIANKEJADIAN DIMASA DATANGDIMASA DATANG.”.”
ERM, Risk Management Handbook for Health Care OrganizationERM, Risk Management Handbook for Health Care Organization
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Risiko di Rumah SakitRisiko di Rumah Sakit
RISIKO KLINISRISIKO KLINIS ::SEMUA ISU YANG DAPAT BERDAMPAK SEMUA ISU YANG DAPAT BERDAMPAK
TERHADAP TERHADAP PENCAPAIAN PELAYANAN PASIENPENCAPAIAN PELAYANAN PASIENYANG BERMUTU TINGGI,AMAN DAN EFEKTIF.YANG BERMUTU TINGGI,AMAN DAN EFEKTIF.
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RISIKO NONKLINISRISIKO NONKLINIS/ Corporate Risk/ Corporate Risk ::
SEMUA ISSU YANG DAPAT BERDAMPAK SEMUA ISSU YANG DAPAT BERDAMPAK TERHADAP TERCAPAINYA TUGAS POKOKTERHADAP TERCAPAINYA TUGAS POKOK
DAN DAN KEWAJIBAN HUKUMKEWAJIBAN HUKUM DARI RUMAH SAKIT DARI RUMAH SAKIT SEBAGAI KORPORASISEBAGAI KORPORASI..
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KATEGORI RISIKO DI RUMAH SAKITKATEGORI RISIKO DI RUMAH SAKIT ::( ( Categories of RiskCategories of Risk ))
Patient carePatient care--related risksrelated risks
Medical staffMedical staff--related risksrelated risks
EmployeeEmployee--related risksrelated risks
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EmployeeEmployee--related risksrelated risks
PropertyProperty--related risksrelated risks
Financial risksFinancial risks
Other risksOther risks
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Risiko yang berhubungan dengan perawatan pasienRisiko yang berhubungan dengan perawatan pasien((Patient care related risksPatient care related risks))
Direct association with Direct association with patient carepatient careConsequences of inappropriate or incorrectly performed Consequences of inappropriate or incorrectly performed
medical treatmentsmedical treatmentsConfidentiality Confidentiality and appropriate release of informationand appropriate release of informationProtection from Protection from abuseabuse, , neglectneglect and assaultand assault
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Protection from Protection from abuseabuse, , neglectneglect and assaultand assaultWas patient Was patient informed of risksinformed of risks??NondiscriminatoryNondiscriminatory treatmenttreatmentAppropriate Appropriate triage and transfertriage and transfer of patients from ERof patients from ERPatient participation in Patient participation in research studiesresearch studies and use of experimental and use of experimental
drugs drugs -- was consent obtained?was consent obtained?Was Was patient dischargedpatient discharged appropriately?appropriately?
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Risiko yang berhubungan dengan tenaga medisRisiko yang berhubungan dengan tenaga medis
((Medical staff Medical staff -- related risksrelated risks))
-- Credential Credential terhadap staf medis ?terhadap staf medis ?
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-- Tindakan medis sesuai Tindakan medis sesuai kompetensikompetensi dan dan prosedur bakuprosedur baku ??
-- Was patient Was patient properly managed properly managed ??
-- Do we have adequately Do we have adequately trained staff trained staff ??
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Risiko yang berhubungan dengan karyawanRisiko yang berhubungan dengan karyawan
((Employee related risksEmployee related risks))
-- Risiko Risiko keselamatan dan kecelakaan kerjakeselamatan dan kecelakaan kerja
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-- Risiko Risiko keselamatan dan kecelakaan kerjakeselamatan dan kecelakaan kerja
-- Maintaining a Maintaining a safe environmentsafe environment -- Employee Health PolicyEmployee Health Policy ::
. reducing risk of . reducing risk of occupational illness and injuryoccupational illness and injury
. providing for the . providing for the treatment and compensationtreatment and compensation of of workers for workworkers for work--related illnesses or injuriesrelated illnesses or injuries
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Risiko yang berhubungan dengan propertyRisiko yang berhubungan dengan property((Property related risksProperty related risks))
Protect assets from losses due to Protect assets from losses due to firesfires, , floodsfloods, etc, etc
Paper and/or electronic recordsPaper and/or electronic records -- patient, business patient, business
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Paper and/or electronic recordsPaper and/or electronic records -- patient, business patient, business and financial and financial -- protected from damage or protected from damage or destructiondestruction
Procedures for Procedures for handling cashhandling cash and safeguarding and safeguarding valuablesvaluables
Bonding and Bonding and insuranceinsurance to protect facility from to protect facility from losseslosses
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Risiko keuanganRisiko keuangan((Financial risksFinancial risks))
–– Bad DebtBad Debt
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–– Meningkatnya suku bungaMeningkatnya suku bunga
–– Global Financial ” tsunami”Global Financial ” tsunami”
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Risiko lainRisiko lain
((Other risksOther risks))
-- Hazardous materialHazardous material management :management :
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-- Hazardous materialHazardous material management :management :
chemical, radioactive, infectious biological chemical, radioactive, infectious biological waste managementwaste management
-- Legal & regulatoryLegal & regulatory risksrisks
-- Reputational RiskReputational Risk
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WHY ?WHY ?
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HOSPITALHOSPITAL
System made up of thousands of System made up of thousands of
interinter--linked processeslinked processes……………..……………..
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things can go wrongthings can go wrong
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Errors are inevitable
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Errors are inevitable
………….but most are preventable
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HOW ?HOW ?
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DIDALAM SISTEM KITA YANG SANGAT KOMPEKS INI …..BAGAIMANA KITA AKAN MENDARAT DENGAN SELAMAT ?
BAHAYA / HAZARD / RISIKO YANG MANA YANG HARUS KITA TANGANI TERLEBIH DAHULU ?
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MANJEMEN RISIKO
. . . ADALAH PENDEKATAN PROAKTIFUNTUK MENGIDENTIFIKASI,MENILAI
2020
UNTUK MENGIDENTIFIKASI,MENILAI DAN MENYUSUN PRIORITAS RISIKO,
DENGAN TUJUAN UNTUK MENGHILANGKAN ATAU
MEMINIMALKAN DAMPAKNYA.
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RISK MANAGEMENT PROCESSRISK MANAGEMENT PROCESS
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RISK MANAGEMENT PROCESSRISK MANAGEMENT PROCESS
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PROSES MANAJEMEN RISIKOPROSES MANAJEMEN RISIKO
KO
MU
NIK
AS
I DA
N K
ON
SU
LTA
SI
MO
NIT
OR
DA
N R
EV
IEW
TEGAKKAN KONTEKS
IDENTIFIKASI RISIKO
2222
KO
MU
NIK
AS
I DA
N K
ON
SU
LTA
SI
MO
NIT
OR
DA
N R
EV
IEW
ANALISA RISIKO
EVALUASI RISIKO
KELOLA RISIKO
ASESMEN RISIKOASESMEN RISIKO
RISK REGISTERRISK REGISTER
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RISK MANAGEMENT TECHNIQUES/TREATMENTSRISK MANAGEMENT TECHNIQUES/TREATMENTS
RISK CONTROLRISK CONTROL ::
-- EXPOSURE AVOIDANCEEXPOSURE AVOIDANCE-- LOSS PREVENTIONLOSS PREVENTION-- LOSS REDUCTIONLOSS REDUCTION
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-- SEGREGATION (SEPARATION OR DUPLICATION)SEGREGATION (SEPARATION OR DUPLICATION)-- CONTRACTUAL TRANSFER FOR RISK CONTROLCONTRACTUAL TRANSFER FOR RISK CONTROL
RISK FINANCINGRISK FINANCING ::
-- RISK RETENTIONRISK RETENTION-- RISK TRANSFERRISK TRANSFER
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IMPLEMENTASI IMPLEMENTASI
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IMPLEMENTASI IMPLEMENTASI MANAJEMEN RISIKO KLINIK MANAJEMEN RISIKO KLINIK
DI RUMAH SAKITDI RUMAH SAKIT
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PRIMUM, NON NOCEREPRIMUM, NON NOCEREFIRST, DO NO HARMFIRST, DO NO HARM
HIPPOCRATES’S TENET HIPPOCRATES’S TENET (460(460--335 BC)335 BC)
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RisikoRisiko SELALU MELEKATSELALU MELEKAT dengandengan
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RisikoRisiko SELALU MELEKATSELALU MELEKAT dengandenganproses pengobatan kepadaproses pengobatan kepada
pasien itu sendiripasien itu sendiri
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RISIKO MENYATU DENGAN SEMUA ASPEK PELAYANAN KESEHATAN,TERMASUK :
• pengobatan dan perawatan kepada pasien;
• menentukan prioritas pelayanan ;
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• pengembangan proyek dan pelayanan ;
• pembelian obat dan produk kesehatan lain;
• instruksi dan follow up kepada pasien.
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CRITICAL POINTS IN CLINICAL RISK MANAGEMENTCRITICAL POINTS IN CLINICAL RISK MANAGEMENT
PROVIDING CARE IN THE PROVIDING CARE IN THE EMERGENCY ROOMEMERGENCY ROOMMAKING A MAKING A DIAGNOSISDIAGNOSIS
ORDERING ORDERING INVESTIGATIONS AND INTERPRETINGINVESTIGATIONS AND INTERPRETINGTHE RESULTSTHE RESULTS
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THE RESULTSTHE RESULTSUNDERTAKING UNDERTAKING INVASIVE PROCEDURESINVASIVE PROCEDURES
DRUG DRUG TREATMENTTREATMENTWARDWARD MANAGEMENTMANAGEMENT
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RISK MANAGEMENT IN RISK MANAGEMENT IN ERER
POTENTIAL ERRORSPOTENTIAL ERRORS
Assessment of emergencies Assessment of emergencies by by insufficiently experienced insufficiently experienced junior staffjunior staff
Inadequate use of Inadequate use of specialist specialist opinionopinion
REDUCING/MINIMISING RISKSREDUCING/MINIMISING RISKS
Experienced clinicians available Experienced clinicians available fullfull--timetime
Involvement of specialist in the Involvement of specialist in the training of stafftraining of staff
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opinionopinion
Inadequate reading of simple Inadequate reading of simple radiographsradiographs
Poor management of Poor management of standard standard situationsituation
Inadequate Inadequate assessment before assessment before dischargedischarge
training of stafftraining of staff
Training of staffTraining of staff
“on call” radiologist“on call” radiologist
Use protocols with sensitivityUse protocols with sensitivity
Senior staff to take responsibility Senior staff to take responsibility for dischargesfor discharges
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REDUCING REDUCING DIAGNOSTIC DIAGNOSTIC ERRORERROR
POTENTIAL ERRORSPOTENTIAL ERRORS
Failure to take a wellFailure to take a well--focused focused case historycase history
Failure to assess the Failure to assess the
REDUCING/MINIMISING RISKSREDUCING/MINIMISING RISKS
Concentrate on key elementsConcentrate on key elements
Better trainingBetter training
Write down conclusions before Write down conclusions before
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Failure to assess the Failure to assess the evidence & evidence & make a DDmake a DD
Inappropriate Inappropriate use of testsuse of tests
Leaving the problem Leaving the problem unexplainedunexplained
Write down conclusions before Write down conclusions before making a planmaking a plan
Define spesific quuestios to be Define spesific quuestios to be answered by chosen testsanswered by chosen tests
Get a second opinionGet a second opinion
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REDUCING THE RISKS OF REDUCING THE RISKS OF INVESTIGATIONINVESTIGATION
POTENTIAL ERRORSPOTENTIAL ERRORS
Clinician Clinician misreadsmisreads visual visual evidence e.g. x ray; ECGevidence e.g. x ray; ECG
Clinician not aware of Clinician not aware of lab resultslab results
REDUCING/MINIMISING RISKSREDUCING/MINIMISING RISKS
Fully trained staff to interpret and Fully trained staff to interpret and report on testsreport on tests
Clinically important results to be Clinically important results to be
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Clinician not aware of Clinician not aware of ward ward observationobservation
Clinician fails to Clinician fails to understand test understand test resultresult
Inappropriate Inappropriate use of testsuse of tests
relayed to clinician urgentlyrelayed to clinician urgently
Ward tests to be supervised and Ward tests to be supervised and results discussed with cliniciansresults discussed with clinicians
Aware of the limits of their Aware of the limits of their competencecompetence
Senior staff to check repeatedlySenior staff to check repeatedly
Careful supervisionCareful supervision
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Reducing the risks of Reducing the risks of invasive proceduresinvasive procedures
Consider The Consider The risk : benefit ratiorisk : benefit ratio
Discuss theDiscuss the procedure with the patientprocedure with the patient
Carrying out the procedure including coping with Carrying out the procedure including coping with potential difficultiespotential difficulties
Ensure that the equipment is in good working order Ensure that the equipment is in good working order
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Ensure that the equipment is in good working order Ensure that the equipment is in good working order and that and that back up equipmentback up equipment is availableis available
If the procedure is not going well obtain If the procedure is not going well obtain help / be help / be prepared to give upprepared to give up
Ensure that the operator has Ensure that the operator has sufficient skillsufficient skill
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Reducing the risks of Reducing the risks of invasive proceduresinvasive procedures
Consider The Consider The risk : benefit ratiorisk : benefit ratio
Discuss theDiscuss the procedure with the patientprocedure with the patient
Carrying out the procedure including coping with Carrying out the procedure including coping with potential difficultiespotential difficulties
Ensure that the equipment is in good working order Ensure that the equipment is in good working order
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Ensure that the equipment is in good working order Ensure that the equipment is in good working order and that and that back up equipmentback up equipment is availableis available
If the procedure is not going well obtain If the procedure is not going well obtain help / be help / be prepared to give upprepared to give up
Ensure that the operator has Ensure that the operator has sufficient skillsufficient skill
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COMMON SPECIFIC FACTORS ASSOCIATED WITH COMMON SPECIFIC FACTORS ASSOCIATED WITH DRUG DRUG ADVERSE EVENTSADVERSE EVENTS
FAILURE TO TAKE ACCOUNT OF DECLINING FAILURE TO TAKE ACCOUNT OF DECLINING RENAL / HEPATIC FUNCTIONRENAL / HEPATIC FUNCTION
FAILURE TO CHECK FOR POSSIBLE FAILURE TO CHECK FOR POSSIBLE ALLERGIC ALLERGIC RESPONSESRESPONSES
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RESPONSESRESPONSES
USING THE USING THE WRONG DRUG NAMEWRONG DRUG NAME OR MEANS OF OR MEANS OF ADMINISTRATIONADMINISTRATION
MISCALCULATION OF MISCALCULATION OF DOSAGEDOSAGE
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REDUCING THE RISKS OF ONGOING REDUCING THE RISKS OF ONGOING WARD CAREWARD CARE
POTENTIAL ERRORSPOTENTIAL ERRORS
Failure to Failure to monitormonitor clinical clinical progressprogress
Failure to recognise that a Failure to recognise that a patient is patient is not making not making satisfactory progresssatisfactory progress
REDUCING.MINIMISING RISKSREDUCING.MINIMISING RISKS
Joint education regarding Joint education regarding appropriate monitoringappropriate monitoring
Regular supervisionRegular supervision
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satisfactory progresssatisfactory progress
Failure to provide Failure to provide appropriate appropriate treatmenttreatment
ShiftShift workingworking
Use spesialist staff Use spesialist staff –– clinician clinician from appropriate unit, nurse from appropriate unit, nurse spesialist, physiotherapistspesialist, physiotherapist
Briefing & deBriefing & de--briefingbriefingSBARSBAR
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PATIENT SAFETY,QUALITY OF CAREPATIENT SAFETY,QUALITY OF CARE
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PATIENT SAFETY,QUALITY OF CAREPATIENT SAFETY,QUALITY OF CARE
AND RISK MANAGEMENTAND RISK MANAGEMENT
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The basic principles for safety The basic principles for safety and quality of careand quality of care
The basic principles for patient safety are The basic principles for patient safety are the the principles for quality of careprinciples for quality of care: :
-- to to do the right thingdo the right thing
for the for the right patientright patient
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for the for the right patientright patient
using the using the right methodright method and and
at the at the right timeright time, and , and
-- to to communicate wellcommunicate well with thewith the patient patient and the rest of the and the rest of the clinical teamclinical team
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“It’s easy gettin’ good players.“It’s easy gettin’ good players.The hard part is gettin’ them to play The hard part is gettin’ them to play
with each other”with each other”
(Casey Stengel)
(Casey
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Communicating Team ???Communicating Team ???
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Quality in HealthcareQuality in Healthcare
…. begins with …. begins with ensuring patient safetyensuring patient safety
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Key reasonsKey reasons
Patients are Patients are more at riskmore at risk than nonthan non--patientspatients
Medical interventions are, by their nature, Medical interventions are, by their nature,
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highhigh--risk procedures risk procedures -- small error marginssmall error margins
Medicine remains an Medicine remains an inexactinexact, hands, hands--on on endeavourendeavour
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Patient safety in contextPatient safety in context
Patient safetyPatient safety is an important component of is an important component of
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risk managementrisk management, , clinical governanceclinical governance, and , and quality improvementquality improvement. .
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4343Australian Patient Safety Foundation
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I. Risk management is not primarily about avoiding or mitigating claims; rather, it is a tool for
improving the quality of care.II. Incident reporting is only one aspect of the identification of
risk. Incident reporting is on the reactive side of risk management. More emphasis needs to be placed on
CONCLUSIONSCONCLUSIONS
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management. More emphasis needs to be placed on
the proactive side.III. Risk management is actually
the business of all stakeholders in the organisation, clinicians and nonclinicians.
IV. The primary focus of risk management should now be clinical governance and patient safety.
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FINAL WORDFINAL WORD
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……Safe care is not an option.It is the right of every patient
who entrusts their care to our Healthcare systems…Sir Liam Donaldson,
Chair, WHO World Alliance for Patient Safety, Forward Programme, 2006–2007
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4646TERIMAKASIHTERIMAKASIH