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"Penelitian ini bertujuan untuk mengetahui gambaran penerapan sistem laporan kesalahan pemberian obat dirawat inap RS X sejak tahun 2000 hingga saat ini.Sistem laporan mulai dari masukan yaitu sistematika dan pelatihan penulisan formulir laporan, kebijakan yaitu SOP (Standard Operating Procedure), komitmen pimpinan, dan dukungan semua departemen, motivasi yaitu sistem insentif dan rasa takut, takut hukuman, takut disalahkan, takut dipecat dan persepsi staf terhadap laporan yaitu hanya kasus besar / fatal saja yang dibuat laporan, tidak untuk kasus-kasus yang kecil. Sistem juga dilihat dari proses yaitu analisa / klarifikasi laporan juga pencarian akar masalah, tindakan koreksi / pencegahan yang dilakukan dan umpan balik serta evaluasi.Metode yang digunakan adalah deskriptif kualitatif dengan model studi kasus, menggunakan 8 kasus 2000-2002 dan 20 kasus hasil observasi 2003. Pengumpulan data primer dilakukan dengan wawancara mendalam dan juga terstruktur terhadap 14 informan dan observasi lapangan terhadap pemberian obat dirawat inap pada waktu tertentu terhadap 32 pasien.Hasil penelitian terlihat masukan masih belum maksimal diterapkan, laporan, kebijakan, motivasi dan persepsi masih perlu diperbaiki terutama rasa takut menulis laporan masih sangat menonjol dari staf yang diwawancara. Pada proses kesalahan terbanyak yang dilaporkan adalah wrong drug sedangkan pada observasi kesalahan terbanyak adalah wrong time yang tidak dilaporkan semua kesalahan pada observasi berjumlah 20 kasus tidak ada laporan karena kasus kecil, tak tahu ada kesalahan dan atasan tidak tahu. Masih ada kasus-kasus yang akar masalahnya belum dicari dengan tuntas, hanya berhenti pada kesalahan orang yang tak menjalankan SOP sehingga tindakan koreksi / pencegahan tidak tepat. Kasus lain karena tulisan dokter yang tak jelas, distraksi telpon tindakan koreksi hanya sebatas pemberitahuan kepada dokter. Umpan balik dan evaluasi tidak pernah dilakukan.Untuk memberikan hasil kerja sistem yang optimal maka perlu disarankan perbaikan-perbaikan sistem dari masukan sampai dengan proses dengan konsisten dapat diterapkan terutama menghilangkan kendala rasa takut untuk menulis dengan sosialisasi rutin.

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Analysis of the Incident Reporting System on Medication Error in the Wards at Hospital X for the Period Year 2000 ? 2003The purpose of this research is to assess the effectiveness of the Implementation of the Incident Report System with regards to Medication Errors in the wards at Hospital X from the period year 2000 to 2003.The design of the research was conducted using descriptive qualitative data obtained from the incident reports filed, hi-depth interviewing, structured interviews and observation studies were conducted from the data obtained from the incident reports.The analysis were conducted using "input" that is, systematic forms, training on how to fill in the forms, existing policies e.g. SOP ( Standard Operating Procedure ), Senior management commitment, multidisciplinary support, staff motivation e.g. reward system, fear of job loss, punishment and staff perception of the error, small/big/fatal. The Process of the system was also analyzed from case-analysis/clarification, finding the root causes, corrective actions /preventive actions, feed back and evaluation.The results of the research showed input should be improved, in particular fear of punishment, job loss. These two factors greatly influenced the "input". In "Process", it was shown that most errors reported were wrong drug errors, and from observation of 19 errors most of them were wrong time errors, no reports were written because of no fatal case, not known by their supervisors, and they did not realized there were errors.In the majority of the incidents reported, the root causes of the incidents occurred were not well analyzed, blaming individuals by not following SOP were prominent. Corrective / preventive actions were not implemented correctly.The analysis also revealed that poor doctors? handwritings and telephone distractions added to the drug error. Limited corrective actions were taken for this. Feedback and evaluation were not done.From this study it is recommended that in order to optimize the implementation of the system, improvement should be made from input until process consistently, in particular, to eliminate fear in filing the incident reports and the system needs to be widely socialized and understood."

"Kompleksnya pelayanan kesehatan di rumah sakit merupakan peluang terjadinya kesalahan, terutama dengan adanya tindakan invasif di bagian bedah. Tujuan penelitian ini adalah menganalisis kejadian dan faktor-faktor yang berkontribusi pada kesalahan medis di bagian bedah rawat inap terkait keselamatan pasien di sebuah Rumah Sakit Umum Daerah. Penelitian menggunakan metode kualitatif dengan desain studi kasus.Hasil penelitian menunjukan bahwa kesalahan medis yang terjadi yaitu 2 kasus KPC, 1 kasus KNC dan 3 kasus KTC. Belum adanya SOP, audit klinis, tempat kerja yang tidak kondusif, kurangnya sarana prasarana, pendidikan, pelatihan, kerja tim dan komunikasi menjadi latar belakang kesalahan.Kesimpulannya adalah kejadian kesalahan medis dipengaruhi oleh faktor organisasi, tempat kerja, individu dan barier. Belum adanya clinical governance dan program keselamatan pasien yang belum berjalan dengan baik. Pelaksanaan keselamatan pasien sangat dipengaruhi oleh pimpinan institusi.

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The complexity of medical services in a hospital creates a change for an error, particularly on an invasive action in surgery unit. This study is aimed to analyse events and contributing factors to medical error in the inpatient unit regarding patient safety in a district hospital.

Using Qualitative with case study design, this study records some medical error events, which are 2 KPC cases, 1 KNC case and 3 KTC cases. Unexisting SOP, clinical audit, unconvenient place of work, lack of equipment/supporting tools, education, training, teamwork and communication are identified as the major causes.

The conclution is that medical errors are influenced by organization factor, work place, individual and defences factors. Unexisting clinical governance and uncontrolled patient safety program. The implementation of patient safety program is greatly influenced by institution leader."

"Tesis ini meneliti tentang faktor-faktor yang berhubungan dengan kejadian medical error oleh dokter di RS. XYZ Palembang, yang meliputi faktor karakteristik dokter, faktor pasien dan faktor lingkungan kerja. Penelitian ini adalah penelitian kuantitatif dengan desain cross sectional.Hasil penelitian menunjukkan bahwa faktor jenis spesialisasi dokter memiliki hubungan bermakna dengan kejadian medical error oleh dokter, dimana dokter spesialis medik operatif dan dokter umum lebih sering melakukan medical error dibandingkan dokter spesialis medik non operatif. Faktor usia dan masa kerja dokter, faktor kenyamanan lingkungan kerja, dan faktor kompleksitas penyakit pasien tidak memiliki hubungan yang bermakna dengan kejadian medical error oleh dokter di RS.XYZ Palembang.

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This research examines the factors assaciate with the medical errors events by doctors at the hospital XYZ Palembang, which include doctors characteristic factors, patient factors and work environment factors. This is a quantitative study with a cross-sectional design.

Results showed that type of physicians specialities have a significant relationship with the medical errors events by doctors. Whereas Operative medical specialists and general practitioners have more frequent of doing medical errors than non-operative medical specialists. Age and work experience of doctors, work environment factors and patient factors have no significant relationship with the medical errors events by doctors at the hospital XYZ Palembang."

"Latar belakang: Kesalahan dalam pelayanan medis merupakan ancaman serius karena dapat menyebabkan pasien cedera, meninggal, dan meningkatkan biaya perawatan kesehatan yang tinggi. 1 Berdasar laporan Institute of Medicine (IOM) tahun 2000, terdapat 3-16% Kejadian Tidak Diharapkan (KTD) pada pelayanan pasien rawat inap di Amerika Serikat, Denmark, Inggris, dan Australia. Laporan JOGC tahun 2015 didapatkan 10% KTD terjadi di bidang obstetri. Data tentang KTD di Indonesia masih sulit didapatkan. Tahun 2007, Jakarta menduduki posisi teratas tentang laporan insiden keselamatan pasien yaitu 37,9%. Dari data Komite Mutu, Keselamatan Pasien, dan Kinerja (KMKK) RSUPN dr Cipto Mangunkusumo tahun 2015 dilaporkan 198 kasus KTD. Tujuan: Mengetahui distribusi kasus KTD di Departemen Obstetri dan Ginekologi RSCM tahun 2015 berdasarkan (1) tempat kejadian, (2) penyebab terjadinya, (3) jenis kegagalan, dan (4) penambahan masa rawat. Metode: Penelitian ini merupakan penelitian deskriptif analisis terhadap kasus KTD yang terjadi di Departemen Obstetri dan Gineklogi RSCM dari Januari hingga Desember 2015. Data didapatkan dari Koodinator Pelayanan Masyarakat (Koyanmas) yang telah dilakukan audit klinik dengan metode Root Cause Analysis (RCA). Hasil: Sepanjang tahun 2015 dilaporkan 36 kasus KTD dan dilakukan audit klinik oleh Tim Manajemen Risiko Klinis. Dari 36 kasus, yang memenuhi kriteria inklusi adalah 24 kasus. Berdasar tempat kejadiannya, terdapat 13 kasus (54%) terjadi di IGD, 4 kasus (17%) di ICU, 4 kasus (17%) di Ruang Operasi, dan 3 kasus (12%) di Ruang Rawat Inap. Berdasar penyebab terjadinya, terdapat 18 kasus (75%) disebabkan kurangnya pengetahuan dan kemampuan tenaga medis, 4 kasus (17%) karena penyebab lain, dan 2 kasus (8%) karena kesalahan teknis. Berdasar jenis kegagalannya, didapatkan 8 kasus (33%) terjadi penundaan perawatan atau tindakan medis, 6 kasus (25%) terjadi kegagalan tindakan medis, 5 kasus (21%) terjadi misdiagnosis, 3 kasus (13%) terjadi ketidaktepatan tata laksana, dan 2 kasus (8%) terjadi kegagalan memberikan peringatan untuk mencegah cedera. Berdasar penambahan masa rawat, data menunjukkan distribusi data yang tidak normal dengan nilai Shapiro-Wilk <0,05. Maka digunakan nilai median yaitu 2 hari. (0-34 hari; 95% IK). Kesimpulan: Sebagian besar KTD di Departemen Obstetri dan Ginekologi RSCM tahun 2015 terjadi di IGD (54%), penyebab terbesar adalah kurangnya pengetahuan dan kemampuan tenaga medis (75%), dan sebagian besar kegagalan terjadi penundaan perawatan atau terapi (33%).

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Background: Medical errors are a serious threat because they can cause injury, death and increase the cost of high health care.1 According to Institute of Medicine (IOM) report in 2000, there are 3-16% of adverse events (AEs) in the care of nursing patients stay in the United States, Denmark, United Kingdom and Australia. In 2015, JOGC report 10% of the AEs occurred in obstetrics. Data on AEs in Indonesia is still difficult to obtain. In 2007, Jakarta occupied the top position regarding patient safety incident reports which is 37.9%. In 2015, from Quality, patient Safety and Performance Committee RSUPN dr. Cipto Mangunkusumo reports 198 cases of AEs. Aim: To obtain the distribution of AEs in the Department of Obstetrics and Gynecology RSCM in 2015 based on (1) place where AEs occured, (2) factor contributing to the AEs (3) failure to prevent the occurrence of the AEs, and (4) the additional length of the stay. Method: This research is a descriptive analysis of the AEs case that occurred in the Department of Obstetrics and Gynecology RSCM from January to December 2015. Data were obtained from the Koordinator Pelayanan Masyarakat (Koyanmas) which had been carried out by a clinical audit using the Root Cause Analysis (RCA) method. Result: In 2015, 36 cases of AEs were reported and a clinical audit was carried out by the Clinical Risk Management Team. From 36 cases, which met the inclusion criteria were 24 cases. Based on the place where AEs occurred, there were 13 cases (54%) in the ER, 4 cases (17%) in the ICU, 4 cases (17%) in the OR, and 3 cases (12%) in the Ward. Based on the factor contributing to the AEs, there were 18 cases (75%) due to lack of knowledge and ability of medical personnel, 4 cases (17%) due to other causes, and 2 cases (8%) due to technical errors. Based on the failure to prevent the occurrence of the AEs, there were 8 cases (33%) delayed treatment or medical treatment, 6 cases (25%) malpractice, 5 cases (21%) misdiagnosis, 3 cases (13%) failure to act based on test results, and 2 cases (8%) failure to take precautions in order to avoid injuries. Based on the additional length of stay, the data showed an abnormal distribution of data with a Shapiro-Wilk value <0.05. We use the median value which is 2 days. (0-34 days; 95% CI). Conclusion: Most of the AEs in the Department of Obstetrics and Gynecology RSCM in 2015 occurred in the ER (54%), the biggest cause was the lack of knowledge and ability of medical personnel (75%), and most of failure due to delay in treatment or therapy (33%)."

"Latar Belakang:Mortalitas dan morbiditas pasien di rumah sakit masih tinggi akibat kurangnya keselamatan pasien. Strategi terpenting untuk meningkatkan keselamatan pasien adalah denganmembangun budaya keselamatan pasien. Tujuandari penelitian ini adalah untuk mengukur pengaruh model budaya positif keselamatan pasien “IDA” terhadap pelaksanaan keselamatan pasien di rumah sakit. Metode.Design adalahaction riset yang terdiri dari: Tahap pertama adalah identifikasi masalah, tahap kedua adalah pengembangan model, tahap ketiga evaluasi efektivitas model. Data dikumpulkan secara kuantitatif dan kualitatif. Kualitatif dengan FGD dan wawancara pada 26 pimpinan dihasilkan empat tema. Penelitian kuantitatif dengan menggunakan instrumen safety attitude questionnaire, quality and safety self efficacy scale, hospital survey on patient safety culture, safety motivation questionnaire scale, safety consciousness scale, dan kuesioner pelaksanaan keselamatan pasien. Tahap dua pengembangan model hasil dari elaborasi tiga teori dan penerapannya dilaksanakan pada 192 orang perawat pelaksana dan 18 orang kepala ruangan di tiga rumah sakit yang telah terakrediatsi paripurna. Tahap tiga diukur efektivitas model pada pelaksanaan keselamatan pasien pada 192 responden kelompok intervensi dan 191 responden kelompok kontrol, sampel diambil dengan cluster random sampling. Hasil Penelitian: Model budaya positif keselamatan pasien “IDA” berpengaruh terhadap dimensi individu: pengetahuan perawat, sikap, motivasi, kesadaran, safety self efficacydan pelaksanaan keselamatan pasien (p<0,05) dan terhadap dimensi individu kepala ruangan: pengetahuan dan sikap kepala ruangan (p<0,05). Pengaruh positif juga terhadap dimensi organisasi dan dimensi lingkungan. Sebagai dampaknya maka terdapat perbedaan secara bermakna pada sasaran keselamatan pasien sebelum dan setelah dilakukan intervensi model “IDA”. Model “IDA” juga diukur efektivitasnya terhadap kelompok kontrol dan semua variabel berbeda bermakna (p<0,05). Kesimpulan dan Saran: model “IDA” berpengaruh terhadap perilaku keselamatan pasien dan capaian sasaran keselamatan pasien oleh perawat. Model “IDA”perlu diterapkan dirumah sakit agar keselamatan pasien tercapai.

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Background: The mortality and morbidity of patients in the hospital are still high due to the lack of patient safety. The most important strategy for improving patient safety is to build a culture of patient safety. The purpose of this study was to measure the effect of a positive culture model of patient safety "IDA" on the implementation of patient safety in hospitals. Method.Design is an action research consisting of: The first stage is problem identification, the second stage is the development of the model, the third stage is the evaluation of the effectiveness of the model. Data were collected quantitatively and qualitatively. Qualitative with FGD and interviews with 26 leaders resulted in four themes. Quantitative research using the instrument safety attitude questionnaire, quality and safety self-efficacy scale, hospital survey on patient safety culture, safety motivation questionnaire scale, safety consciousness scale, and patient safety implementation questionnaire. The second stage of the development of the model results from the elaboration of three theories and its application was carried out on 192 implementing nurses and 18 heads of rooms in three hospitals who had been fully accredited. Stage three measured the effectiveness of the model in the implementation of patient safety in 192 respondents in the intervention group and 191 respondents in the control group, the sample was taken by cluster random sampling. Results: The positive culture model of patient safety "IDA" affects the individual dimensions: knowledge of nurses, attitudes, motivation, awareness, safety self efficacy and implementation of patient safety (p <0.05) and on the individual dimensions of the head of the room: knowledge and attitude of the head. room (p <0.05). The positive influence is also on the organizational and environmental dimensions. As a result, there are significant differences in patient safety goals before and after the "IDA" model intervention. The effectiveness of the "IDA" model was also measured against the control group and all variables were significantly different (p <0.05). Conclusions and suggestions: the "IDA" model affects the implementation and achievement of patient safety goals. The "IDA" model needs to be applied in hospitals so that patient safety is achieved."

"This compendium of case studies on patient safety - told from the perspective of the patient and family - illustrates 24 stories of preventable health care errors that led to irreparable patient harm. The reader is guided through a structured analysis of the events, eliciting lessons learned and strategies for preventing similar events in the future. Learning objectives for each case facilitate the reader's development of a set of core competencies related to improving safety and quality of health care.Contents"

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