RISK MANAGEMENT TO IMPROVE PATIEN TIENT T SAFE SAFETY TY
ARJATY W DAUD
Nama Alamat Tmpt / tgl. Lahi Status Email Hp
: dr. Arjaty W. Daud, MARS : Jl Kemang Timur Timur XIV / 56 Jak Sel : Manado,17 Januari 1969 : Menikah :
[email protected] [email protected],, : 0812 1830 7169
PENDIDIKAN S-1 Fakultas Kedokteran Universitas Universitas Sam Ratulangi - Manado , Lulus 1995 S-2 Fakultas Kesehatan Masyarakat, Masyarakat, KARS Universitas Indonesia, Lulus 2005 PELATIHAN / SEMINAR 2011 : Practicum Acreditation JCI Seoul Patient Safety Safety Course, Singapura 2010 : Safety in Healthcare, Kuala Lumpur 2009 : Hospital Management Management Asia, Vietnam Vietnam Course Risk Management PRMIA Jakarta 2007 : New Perspektif, Conferrence ASHRM, Chicago USA Certified Profesional Healthcare Healthcare Risk Management course, Chicago USA Risk Management Base Training, Joint Commision Resources (JCR) Resources (JCR) Patient Safety Up Date, Joint Commision International (JCI) Singapura 2005 : Lead Audior ISO 9001 – 2000, International Registered Certificated 2/28/14 Arjaty Daud/Risk/2014 Auditor (IRCA)
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Nama Alamat Tmpt / tgl. Lahi Status Email Hp
: dr. Arjaty W. Daud, MARS : Jl Kemang Timur Timur XIV / 56 Jak Sel : Manado,17 Januari 1969 : Menikah :
[email protected] [email protected],, : 0812 1830 7169
PENDIDIKAN S-1 Fakultas Kedokteran Universitas Universitas Sam Ratulangi - Manado , Lulus 1995 S-2 Fakultas Kesehatan Masyarakat, Masyarakat, KARS Universitas Indonesia, Lulus 2005 PELATIHAN / SEMINAR 2011 : Practicum Acreditation JCI Seoul Patient Safety Safety Course, Singapura 2010 : Safety in Healthcare, Kuala Lumpur 2009 : Hospital Management Management Asia, Vietnam Vietnam Course Risk Management PRMIA Jakarta 2007 : New Perspektif, Conferrence ASHRM, Chicago USA Certified Profesional Healthcare Healthcare Risk Management course, Chicago USA Risk Management Base Training, Joint Commision Resources (JCR) Resources (JCR) Patient Safety Up Date, Joint Commision International (JCI) Singapura 2005 : Lead Audior ISO 9001 – 2000, International Registered Certificated 2/28/14 Arjaty Daud/Risk/2014 Auditor (IRCA)
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PENGALAMAN KERJA 2013 : Konsultan JCI RSU Kanujoso Balikpapan, RSUD Kraton Pekalongan, RSUD RSUD Sleman Jogjakarta, RS MMC 2012 : Konsultan JCI RSUP Fatmawati, RSUP Wahidin Sudirohusodo Makasar, RS Medistra 2011 : Konsultan Konsultan JCI RSCM, Konsultan Manajemen Manajemen Risiko & Keselamatan amatan Pasien RS Tarakan Kaltim 2010 : 2010 : Konsultan Manajemen Manajemen risiko RSUP Fatmawati Jakarta, RS Bieuren, euren, RS Lhoksemawe Aceh 2009 : Konsultan Manajemen risiko & Kes Pasien RS Wahidin Makasar, RS Pelni Jakarta 2007 2006 2004 - 2005 2003
Konsultan RS Aini, RS Sardjito : Direktur RS Zahirah Konsultan Manajemen risiko RS Persahabatan, RS Dharmais Konsultan Manajemen RS Asri, Konsultan Manajemen RS Medika BSD, : Manajer Manajer Operasion Operasional al Medika Medika Plaza Plaza Internati International onal Clinic Clinic : General Manajer Cempaka Medical Centre
2003 - 2004 2004 2002 - 2003 2000 - 2001 2001
: Direktur Direktur Operasion Operasional al RS Sentra Sentra Medika Medika : Wakil Wakil Direktur Direktur Medik & Asist Direktur RS Sentra Sentra Medika Medika : Kepala Kepala Bagian Bagian Humas Humas RS MMC MMC
1999 - 2000 2000 1999
: Kepala Kepala Bagian Bagian Rehabi Rehabilita litasi si Medik Medik RS MMC : Asisten Konsultan WHO Umbrella Project Depkes
1996 -1999 -1999
: Kepala Kepala Puskesm Puskesmas as Sindang Sindang Barang Barang Kabupaten Kabupaten Cianj Cianjur ur
ORGANISASI 2007 – 2012 : Ketua Bidang IV (Pelaporan Insiden) KKP RS PERSI , Sterring Committe KKP RS 2005 - Saat ini:Ketua Institut Manajemen Risiko Klinis (IMRK) / ICRMI Member of ASQ (American Quality Society), Member of Profesional Risk Management International Association
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PRIMUM, NON NOCERE FIRST, DO NO HARM
IOM (2000): 44.000 – 98.000
Adv event Estimasi biaya: $17 - $50 milyar Meninggal krn : KLL : 43,458 Cancer : 42,297 AIDS : 16,516
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Redesign system Fear Fear of Blame
Reporting
(Improve)
Leassons Learned
Investigation & Analysis
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Risk vs. Medical Error Potential Failure
Actual Failure
Medical Errors
Risks
What is going wrong With this process?
What could go wrong With this process?
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Actual SE
Response JCI can review RCA Add to SE Database
Examples SE Policy
Patient death from medication misadministration
"reviewable" Conduct RCA Not subject to SE definition Evaluate process at triennial survey
On-going data collection
Adverse events
Significant misadministration -- patient survives
"Important single events"
Full range of Near Miss events,
Majority of medication errors
High Risk Processes 2/28/14
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Pasien tidak terpapar
Near Miss (KNC=Kejadian NYARIS CIDERA) - ERROR, diket, dibatalkan (prevention)
Medical Error Procces of care error Kesalahan proses yg dpt dicegah : • Error in planning • Error in Execution
Krn berbuat : commission Krn tidak berbuat : omission
Tidak cidera
No Harm Event
(KTC=Kejadian TIDAK CIDERA)
Pasien terpapar
- Dpt obat “c.i.”, tdk timbul (chance) - Dpt obat “c.i.”, diket, beri anti-nya (mitigation)
Pasien cidera
Adverse Event
(KTD=Kejadian Tdk Diharapkan) Dpt dicegah
significant potential for harm situation
reportable circumstance
Tidak cidera
(KPC=Kondisi Potensi Cedera)
Proses of Care Non Error
Pasien terpapar
Pasien cidera
Adverse Event
(KTD=Kejadian Tdk Diharapkan) -TIDAK Dpt dicegah
JENIIS INSIDEN YG HARUS DILAPORKAN 1. KEJADIAN SENTINEL 2. KEJADIAN TIDAK DIHARAPKAN (KTD) Insiden yang mengakibatkan cedera pada pasien 3. KEJADIAN TIDAK CEDERA (KTC) Insiden yang sudah terpapar kepada pasien tapi tidak menimbulkan cedera 4. KEJADIAN NYARIS CEDERA (KNC) Insiden yang belum terpapar kepada pasien
KONDISI POTENSIAL RISIKO / CEDERA YANG HARUS DILAPORKAN KONDISI POTENSIAL CEDERA (KPC) Kondisi yang berpotensial menimbulkan cedera tapi belum terjadi insiden 2/28/14
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Passenger
Check in
Boarding
KTP = Tiket ?
Boarding pass
Pilot
Sehat ?
Plane
check
Bagage
screening
Pre take off Hitung / check
check
check
check
check
screening
Paul Barach, MD, MPH, Univ of Miami Medical School
DOMAINS OF QUALITY
“Safety” : reduce risk
Safe
Meeting customer value & expectation s
Best practice, EBM
Practice consistent with Current medical knowledge
Customization
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STOP
PERSON APPROACH :
Focuses on the errors & violations Of individuals
Who ? Process of care Input
Activities
Patient Impact
Health Services
Health Outcome
Why ?
!
SYSTEM
How ?
APPROACH :
Bukan berarti semua orang dapat melakukan kecerobohan
Traces the causal factors back into the system As a whole Setiap orang harus waspada dan bertanggung jawab terhdp apa yg dikerjakan Arjaty/IMRK/2008
MEDICAL ERROR
Slips
Error in Arjaty/IMRK/2010
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Similar Vials: Cefazolin and Vecuronium
Similar Vials: Atropine & Phenylephrine
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Lotrison or Lotrimin ?
Doxorubicin or Daunorubicin ?
Coumadin or Kemadrin ?
Pentobarbital or Phenobarbital ?
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Intended dose of 4 units in patient history interpreted as 44 units. “U” should be written out as “unit.” Arjaty/IMRK/2008
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Wayne meninggal dunia di “QUeen’s Medical Center”, Nottingham, Inggris, tepat j 08.00 setelah diberi “Vincristine” yang harusnya IV, tapi diberikan ke tulang belakang. Yang harusnya disuntikkan di tulang belakang adalah “Cytosine”. Dr Feda M dikenai hukuman 8 bulan penjara setelah mengakui secara tidak sengaja “membunuh” pasien leu kemia yang usianya sangat muda. Arjaty/IMRK/2008
Risk vs. Medical Error Potential Failure
Actual Failure
Medical Errors
Risks
What is going wrong With this process?
What could go wrong With this process?
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Risiko di Rumah Sakit !
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9"#"!@9@# 6)()'? 6&9"C ("')* •Kegiatan berupa identifikasi dan evaluasi untuk mengurangi risiko cedera dan kerugian pada pasien, karyawan rumah sakit, pengunjung dan organisasinya sendiri (The Joint Commission on Accreditation of Healthcare Organizations / JCAHO). • Kegiatan meminimalkan bahaya terhadap pasien, kegiatan untuk menciptakan lingkungan yang aman bagi karyawan, pasien dan pengunjung (ASHRM) 32
Patient care Related Risks
Medical Staff Related Risks
Employee Related Risks
Other Risks
Financial Risks
Property Related Risks Roberta Caroll, editor : Risk Management Handbook for Health Care Organizations, 4th edition, Jossey Bass, 2004
MANAJEMEN RESIKO TERINTEGRSI
•Patient Safety •Health & Safety
Lessons learned
•Clinical •Employment
O R G R A S N I S A S I
Identify and Reduce Unanticipated Adverse Events !
Leaders adopt a framework that: !
! !
!
!
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Risk Management Framework
Risk identification & prioritization, Risk reporting and management Investigation of adverse events Management of related claims
Conducts and documents a proactive risk reduction annually Take action to redesign high-risk processes based on analysis
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Risk Identification
Risk Assessment
Risk Reduction
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Risk Management Steps Understand Risk 2. Identify High Risk Processes (Get input from 1.
stakeholders) 3. 4. 5. 6. 7. 8.
Conduct a Risk Assessment Conduct Proactive Risk Analysis Develop Mitigating Strategies Develop Contingency Plans Implement Strategies and Plans Reassess Risks 2/28/14
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Step 1: Establish Risk Management Program !
Examples: !
!
!
Sub-committee of the overall QIPS program A risk management coordinator integrated into the QIPS program
Need to ensure organization-wide, interdisciplinary representation. 2/28/14
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Step 2: Identify Organization-Wide High Risks Processes !
Sources of information: !
!
! !
!
!
!
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Patient complaints Incident reports (OVAR) Medication error reports (MMU.7.1) Adverse event (medical error) monitoring (QPS.6-8) Environmental assessments (FMS.3.1) Ifection control assessments (PCI.5) Insurance or legal claims Safety walks or tracers 2/28/14
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)D@#*)E)'"() 6)()'? Reaktif
Proaktif
!
Incident reporting (Laporan Insiden)
!
Case Report
!
Complaint
!
Claim data
!
Clinical care review
!
Audit Medis
!
Occurrence Screening / Medical Record Review
!
Survey / Self Assesment Arjaty/IMRK/2008
Categories of High Risk Processes • Types of infections, including organisms of epidemiological significance • At-risk patient or resident populations • Supplies and equipment risks • Emergency preparedness • Environmental issues • Geographic considerations specific risk process • Community considerations Identify In each category 2/28/14
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Is This a High Risk Process?
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Step 3: Prepare a Prioritized List of High Risk Processes !
!
Have leaders use prioritization criteria to prepare list List should reflect high risk process processes for which failure has or will result in harm to patients, staff, visitors, or contract workers
You need standardized numerical values or criteria to assess risks!!! 2/28/14
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Risk Ranking and Prioritization Methods !
!
!
List each high risk process For each high risk process, assign a score (H,M,L) for each prioritization criteria Create a ranked prioritize list of high risk processes
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Risk Ranking and Prioritization Criteria !
Usual prioritization criteria are: Probability or likelihood of occurrence Risk of harm (criticality) or impact System capacity or preparedness !
!
!
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Risk Ranking and Prioritization Criteria !
!
Sometimes criteria given numerical weight of 1-5 or 1-10 (refer to prioritization tool) Each criteria scored as low, medium, or high which is 1,3,5 or 1,5,9, or scored from 1-10 Assigning numbers to ordinal scales
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Prioritization Tool
Criteria Score
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Step 4: Use Proactive Risk Reduction Tool for Analysis and Prioritization !
Tools: !
!
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Failure Mode Effect Analysis- FMEA Healthcare Failure Mode Effect Analysis – HFMEA Hazard Vulnerability Analysis - HVA
Apply analysis tool to a list of high risk processes, starting with the highest priority
!
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Step 5: Develop and Implement Solutions !
!
!
It is the job of management not only to assess risk, but also to identify effective courses of action to eliminate or mitigate that risk This commitment to implementing risk reduction methods transforms risk assessment into risk management Use a FMEA/RCA method to identify root causes and potential solutions
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CONCLUSION QUALITY MANAGE R
RISK MANAGER
Improved collaboration between risk management, patient safety and quality improvement will contribute to an organization’s success in enhancing Patient safety Program and minimizing patient harm. 2/28/14
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