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UTAMAKAN
KESELAMATAN
PASIEN
PATIENT SAFETY AS A KEY
COMPONENT OF RISK MANAGEMENT
Dr.Adib A.Yahya MARS
Ketua Umum PERSI
Workshop Keselamatan Pasien Dan Manajemen
Risiko Klinis
RS ST.CAROLUS Jakarta 1 3 NOV 2006
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2. Why?
1. What?
3. How?
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DEFINISI RISIKODEFINISI RISIKO
RISIKO ADALAH :RISIKO ADALAH :
SUATU POTENSI ANCAMAN YANG DAPATSUATU POTENSI ANCAMAN YANG DAPAT
TIMBUL DARI PROSES SAAT INI ATAUTIMBUL DARI PROSES SAAT INI ATAUKEGIATAN YANG AKAN DATANGKEGIATAN YANG AKAN DATANG
ERM, Risk Management Handbook for Health Care OrganizationERM, Risk Management Handbook for Health Care Organization
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RISK IS :RISK IS :
A possible event or circumstances that canA possible event or circumstances that canhave negative influences on the Enterprise inhave negative influences on the Enterprise inquestion.question. (ERM)(ERM)
Its impact can be on the very existence:Its impact can be on the very existence:-- the resources (human and capital)the resources (human and capital)
-- the products and services, orthe products and services, or-- the customers of the Enterprise,the customers of the Enterprise,
-- as well as external impact on Society,as well as external impact on Society,Markets or the EnvironmentMarkets or the Environment
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RISIKO ADALAH :RISIKO ADALAH : FUNGSI DARIFUNGSI DARIPROBABILITAS (CHANCE, LIKELIHOOD)PROBABILITAS (CHANCE, LIKELIHOOD)
TENTANG KEJADIAN YANG TIDAKTENTANG KEJADIAN YANG TIDAKDIINGINKAN, DAN TINGKAT KEPARAHANDIINGINKAN, DAN TINGKAT KEPARAHAN
DARI DAMPAK YANG DITIMBULKANDARI DAMPAK YANG DITIMBULKAN
probability of an accidentprobability of an accident consequence in lost money or deathconsequence in lost money or death
RiskRisk
events per time periodevents per time period per eventper event
Risk = Probability (of the Event) ConsequenceRisk = Probability (of the Event) Consequence
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RISIKO DI RUMAH SAKITRISIKO DI RUMAH SAKIT
DiDi rumahrumah sakitsakit terdapatterdapat duadua komponenkomponengovernancegovernanceyaitu :yaitu :Corporate governanceCorporate governance dandan Clinical governanceClinical governance..
11) Pelaksanaan) Pelaksanaan Corporate governanceCorporate governance menimbulkanmenimbulkanrisiko perusahaan (risiko perusahaan (corporate risks)corporate risks) sepertiseperti ::
Risiko asetRisiko asetRisiko pendapatan bisnisRisiko pendapatan bisnis
Risiko tuntutan hukumRisiko tuntutan hukum
Risiko kelalaian karyawanRisiko kelalaian karyawan
Risiko akibat kelemahan sistem operasional prosedurRisiko akibat kelemahan sistem operasional prosedur
Risiko korupsi, tindak kriminal, ketidakjujuranRisiko korupsi, tindak kriminal, ketidakjujurankaryawankaryawan
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2)2) Pelayanan medis / klinisPelayanan medis / klinis menyebabkanmenyebabkan
timbulnya risiko klinis (timbulnya risiko klinis (clinical risk)clinical risk) sepertiseperti ::
Risiko kesalahan medisRisiko kesalahan medis (Medical errors)(Medical errors) Risiko kejadianRisiko kejadian--kejadian kritis (kejadian kritis (CriticalCritical
incidents)incidents) Risiko komplain pasienRisiko komplain pasien
Risiko klaim pasienRisiko klaim pasien
Risiko malpraktekRisiko malpraktek RisikoRisiko infeksiinfeksi nosokomialnosokomial
Risiko K3Risiko K3
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RISK MANAGEMENT
SUATU PENDEKATAN
PROAKTIF DENGAN TUJUAN
UNTUK IDENTIFIKASI,PENILAIAN DAN
PRIORITASISASI RISIKO, GUNAMENGHILANGKAN ATAU
MEMPERKECIL DAMPAKNYA
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HOSPITAL RISK MANAGEMENTHOSPITAL RISK MANAGEMENT
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}
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CLINICAL RISK MANAGEMENTCLINICAL RISK MANAGEMENT
Clinical Risk Management is an approach toClinical Risk Management is an approach to
improving the quality and safe delivery of healthimproving the quality and safe delivery of healthcare by :care by :
-- Placing special emphasis on identifyingPlacing special emphasis on identifyingcircumstances that put patients at risk of harm,circumstances that put patients at risk of harm,
andand
--Acting to prevent or control those risksActing to prevent or control those risks
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KATEGORI DAN RUANG LINGKUP MANAJEMEN RISIKO :KATEGORI DAN RUANG LINGKUP MANAJEMEN RISIKO :
Risiko yang berhubungan dengan perawatan pasienRisiko yang berhubungan dengan perawatan pasien(Patient care related risks)(Patient care related risks) Pelayanan yang tidak sesuai SOPPelayanan yang tidak sesuai SOP
Akibat pengobatan yang tidak sesuaiAkibat pengobatan yang tidak sesuai Informed consentInformed consent
Diskriminasi pengobatanDiskriminasi pengobatan
Kehilangan barang milik pasienKehilangan barang milik pasienRisiko yang berhubungan dengan tenaga medisRisiko yang berhubungan dengan tenaga medis
(Medical staff related risks)(Medical staff related risks)
Credential terhadap staf medis ?Credential terhadap staf medis ? Tindakan medis sesuai kompetensi dan prosedur bakuTindakan medis sesuai kompetensi dan prosedur baku
Risiko yang berhubungan dengan karyawanRisiko yang berhubungan dengan karyawan
(Employee related risks)(Employee related risks) Risiko keselamatan dan kecelakaan kerjaRisiko keselamatan dan kecelakaan kerja
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Risiko yang berhubungan dengan propertyRisiko yang berhubungan dengan property
(Property related risks)(Property related risks)
Kerugian akibat kebakaran, bencana dllKerugian akibat kebakaran, bencana dll
Kehilangan laporan dan dokumenKehilangan laporan dan dokumen
Kehilangan barang berhargaKehilangan barang berharga
Risiko keuanganRisiko keuangan (Financial risks)(Financial risks)
Bad DebtBad DebtMeningkatnya suku bungaMeningkatnya suku bunga
Risiko lainRisiko lain (Other risks)(Other risks)Masalah limbah rumahMasalah limbah rumah
DLL.DLL.
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Hosp
osp
Risk
isk
Mgtgt
PatientPatient
R.RiskR.RiskMedicalMedical
StaffStaffR.RisksR.Risks
EmployeeEmployee
R RisksR RisksPropertyProperty
R RisksR Risks
OtherOther
RisksRisks
PatientPatientSafetySafety
Health Risk Mgt for HCO /Health Risk Mgt for HCO /
Hosp : Health Care Risk MgtHosp : Health Care Risk Mgt
is concerned with ais concerned with atremendous variety of issuestremendous variety of issues
and situations that hold theand situations that hold the
potential for liability orpotential for liability or
casualty loses for ancasualty loses for an
organizationorganization
Roberta Caroll, editor : Risk Management Handbook
for Health Care Organizations, 4th edition, Jossey
Bass, 2004
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WHY IS RISK MANAGEMENT AN ISSUEWHY IS RISK MANAGEMENT AN ISSUE
IN HEALTHCARE?IN HEALTHCARE?
. because a breach of their duty ofcare has serious and/or far reaching
consequences.
WHY IS RISK MANAGEMENT AN ISSUEWHY IS RISK MANAGEMENT AN ISSUE
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WHY IS RISK MANAGEMENT AN ISSUEWHY IS RISK MANAGEMENT AN ISSUE
IN HEALTHCARE?IN HEALTHCARE?
Health Care is a Risky Business
Health Care is a Risky Business ... Financially
Health Care is a Risky Business ... for staff
THE PROBLEM WITH
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THE PROBLEM WITHHEALTHCARE
BANYAK SEKALI PERMASALAHAN YANG
BERSIFAT PERORANGAN. OTONOMI PROFESI YANG TINGGI
TINGKAT REGULASI YANG RENDAH
TINGGINYA TINGKAT EKSPEKTASIPASIEN DAN RENDAHNYA
PEMBERDAYAAN PASIEN HUBUNGAN ANTARA RISIKO DAN
PERMINTAAN
H i l Ri k i bH i l Ri k i b
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Hospital Risk management is about :Hospital Risk management is about :
MinimisingMinimising the likelihood of patients fromthe likelihood of patients fromcoming harmcoming harm
Creating a safe environment for all staff andCreating a safe environment for all staff andvisitorsvisitors
Maintain the good reputation of the Hospital byMaintain the good reputation of the Hospital byconducting relationship with openness andconducting relationship with openness andhonesty and delivering effective and efficienthonesty and delivering effective and efficient
servicesservices Ensuring compliance with all applicableEnsuring compliance with all applicable
legislationlegislation
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Providing a comprehensive approach to riskProviding a comprehensive approach to risk
assessment and managementassessment and management
Assisting with compliance against national,Assisting with compliance against national,regional and local priorities for actionregional and local priorities for action
Supporting and complementing the newSupporting and complementing the new
organisationalorganisational structurestructure
Promoting just and fair culture where staff arePromoting just and fair culture where staff are
encouraged to report risk, incidents and nearencouraged to report risk, incidents and nearmissesmisses
S A AG T C CA GO A CRISK MANAGEMENT & CLINICAL GOVERNANCE
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RISK MANAGEMENT & CLINICAL GOVERNANCERISK MANAGEMENT & CLINICAL GOVERNANCE
The Elements of Clinical Governance
Clinical governance is an aggregation of service improvement processes that are
regulated by a single ideology.
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Patient safety is a key componentPatient safety is a key component
of risk managementof risk management
Patient SafetyPatient Safety Risk ManagementRisk Management
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Patient SafetyPatient SafetyRisk ManagementRisk Management..
Step 1Step 1 Build a safety cultureBuild a safety culture Create a culture that is open and fairCreate a culture that is open and fair
Step 2Step 2 Lead and support your staffLead and support your staff Establish a clear and strong focus onEstablish a clear and strong focus on
patient safety throughout yourpatient safety throughout your
organisationorganisation
Step 3Step 3 Integrate your risk managementIntegrate your risk managementactivityactivity
Develop systems andDevelop systems andprocesses to manage yourprocesses to manage your
risks and identify and assessrisks and identify and assess
things that could go wrongthings that could go wrong
Step 4Step 4 Promote reportingPromote reporting Ensure your staff can easily reportEnsure your staff can easily report
incidents locally and nationallyincidents locally and nationally
Step 5Step 5 Involve and communicate with patients and theInvolve and communicate with patients and the
publicpublicDevelop ways to communicate openlyDevelop ways to communicate openly
with and listen to patientswith and listen to patients
Step 6Step 6 Learn and share safety lessonsLearn and share safety lessons Encourage staff to use root causeEncourage staff to use root cause
analysis to learn how and why incidentsanalysis to learn how and why incidents
happenhappen
Step 7Step 7 Implement solutions to prevent harmImplement solutions to prevent harm Embed lessons through changes toEmbed lessons through changes to
practice, processes or systemspractice, processes or systems
www.wmin.ac.uk
RISK MANAGEMENT
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RISK MANAGEMENT
CONCEPT
CULTURAL
TRANSFORMATION
INTERGRATED RISK
MANAGEMENT
HOW ?HOW ?METHODE RISK MANAGEMENT
CYCLE
LESSONS LEARNED
PRIMUM NON NOCEREPRIMUM NON NOCERE
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PRIMUM, NON NOCEREPRIMUM, NON NOCERE
FIRST, DO NO HARMFIRST, DO NO HARM
HIPPOCRATESHIPPOCRATES
S TENETS TENET
(460(460--335 BC)335 BC)
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Patient SafetyPatient Safety bukanbukan kegiatankegiatanyangyang barubaru..
Patient SafetyPatient Safety sudahsudah harusharus menyatumenyatu
dengandenganprosesproses pengobatanpengobatan kepadakepadapasienpasien ituitu sendirisendiri
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Patient Safety/Risk managementPatient Safety/Risk managementprograms were born ofprograms were born ofexistingxisting
practicesractices
that werethat were expandedexpanded,,formalizedformalized,, andand centralizedentralized..
CURRENT SITUATION
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incidentreporting
patient
complaints
variance analysisclinical indicator
data
medical negligence
claims
complication
audit
CURRENT SITUATION
HRRI.Healthcare Risk Resources InternationalHRRI.Healthcare Risk Resources International
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BASIC CONCEPTBASIC CONCEPT
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CONTRIBUTING FACTORS INFLUENCINGCONTRIBUTING FACTORS INFLUENCING
CLINICAL PRACTICECLINICAL PRACTICE
1. PATIENT FACTORS
a. Condition complexity and seriousness
b. Language and communication
c. Personality and social factors
2. TASK AND TECHNOLOGY FACTORS
a. Task design and clarity of structure
b. Availability and use of protocols
c. Availability and accuracy of test results
d. Decision-making aids
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3. INDIVIDUAL (STAFF) FACTORS
a. Knowledge skills
b. Competence
c. Physical and mental health
4. TEAM FACTORS
a. Verbal communication
b. Written communication
c. Supervision and seeking help
d. Team structure
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5. WORK ENVIRONMENTAL FACTORS
a. Staffing levels and skill mix
b. Workload and shift patterns
c. Design, availability and maintenance of equipment.
d. Administrative and managerial support
e. Environmentf. Physical
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6. ORGANIZATION AND MANAGEMENT FACTORS
a. Financial resources and constraints
b. Organizational structure
c. Policy, standards and goals
d. Safety culture and priorities
7. INTERNATIONAL FACTORS
a. Economic and regulatory factors
b. Link with other origination line.
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INTEGRATED RISK MANAGEMENTINTEGRATED RISK MANAGEMENT
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Integrated risk management
ntegrated risk management is theis the
process ofprocess ofidentification assessmentdentification assessment
analysis
nalysis andand managementanagement of all risks andof all risks and
incidents forincidents for every level of anvery level of an
organisationrganisation
,, and the aggregation of theand the aggregation of theresults at a corporate level.results at a corporate level.
IN PRACTICE, INTEGRATED RISK MEANS :IN PRACTICE, INTEGRATED RISK MEANS :
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Integrating all risk management functions ( patient safety,Integrating all risk management functions ( patient safety,
OHS, complaints, clinicalOHS, complaints, clinical litigation,etclitigation,etc.).)
IntegratingIntegrating modernisationmodernisation and clinical governanceand clinical governanceactivity to unite strategies and improve outcomes andactivity to unite strategies and improve outcomes and
safety for patients.safety for patients.
Integrating all sources of information related to risk andIntegrating all sources of information related to risk and
safety.safety.
Integrating risk assessments of all types of risk forIntegrating risk assessments of all types of risk for
organisationorganisation at every levelat every level
IN PRACTICE INTEGRATED RISK MEANS ( tIN PRACTICE INTEGRATED RISK MEANS ( td)d)
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IN PRACTICE, INTEGRATED RISK MEANS : (contIN PRACTICE, INTEGRATED RISK MEANS : (contd)d)
A consistent approach to the training, management,A consistent approach to the training, management,
analysis and investigation for all risksanalysis and investigation for all r isks
Incorporating all risk into anIncorporating all risk into an organisationorganisationss riskrisk
assessmentassessment programmeprogramme and risk register, using riskand risk register, using risk
assessment tools to identify all potential risks toassessment tools to identify all potential risks to
organisationalorganisational strategy and policy.strategy and policy.
Integrating processes and decisions about all r isk intoIntegrating processes and decisions about all r isk into
future business and strategic plansfuture business and strategic plans ..
BASIC CONCEPTSBASIC CONCEPTS
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I. Risk management is not primarily about avoiding ormitigating claims; rather, it is a tool for improving the
quality of care. Risk management is also as much about
learning from claims as it is about mitigating claims.
II. Risk management is not simply the reporting of patient
safety incidents.
Incident reporting is only one aspect of the identification of
risk. In one sense, incident reporting is on the reactive side
of risk 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
patient safety
Basic questions addressed by risk managementBasic questions addressed by risk management
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Basic questions addressed by risk managementBasic questions addressed by risk management
What could go wrong ?What could go wrong ? Risk identificationRisk identif ication
What are the chances of it goingWhat are the chances of it going Risk analysis andRisk analysis and
evaluationevaluation
wrong and what would be the impact ?wrong and what would be the impact ?
What can we do to minimize the chanceWhat can we do to minimize the chance Risk treatment. TheRisk treatment. The
cost ofcost of
of this happening or to mitigate damageof this happening or to mitigate damage prevention isprevention is
compared withcompared with
when it has gone wrong ?when it has gone wrong ? the cost of getting it wrongthe cost of getting i t wrong
What can we learn from things thatWhat can we learn from things that Risk control; sharing andRisk control; sharing and
have gone wrong ?have gone wrong ? LearningLearning
Royal College of Obstetricians andRoyal College of Obstetricians and Gynaecologists.ClinicalGynaecologists.Clinical Governance Advice No.2Governance Advice No.2
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METHODEMETHODE
RISK MANAGEMENT PROCESSRISK MANAGEMENT PROCESS
RISK MANAGEMENT TOOLSRISK MANAGEMENT TOOLS
RISK MANAGEMENT PROCESSRISK MANAGEMENT PROCESS
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Risk Identi fication
Risk AnalysisCommunication
&ConsultationEvaluation and
Prioritisation
RiskAss
essment
Monitor
&
Review
Risk Treatment
IDENTIFIKASIIDENTIFIKASI
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RiskRisk
IdentificationIdentification
Incident reportingIncident reporting
Case ReportCase Report
ComplaintComplaint
Claim dataClaim data
Clinical care reviewClinical care review
AuditAudit MedisMedis
Occurrence Screening /Occurrence Screening /
Medical Record ReviewMedical Record Review
Survey / SelfSurvey / SelfAssesmentAssesment
ANALISIS RISIKOANALISIS RISIKO
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ANALISIS RISIKOANALISIS RISIKO
Matrix
Assesment
(Risk Grading)
RCA (Root Cause
Analysis)
FMEA (Failure
Mode & EffectsAnalysis)
ANALYZE
RISK
EVALUASI RISIKO
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EVALUASI RISIKO
Evaluasi
Risiko
Risk Ranking
Priority the risk
PENATALAKSANAAN RISIKOPENATALAKSANAAN RISIKO
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Penatalaksanaan
Risiko
StrategiStrategipenatalaksanaanpenatalaksanaan risikorisiko dibagidibagi 2,2,yiyi ::
1.1. KontrolKontrol risikorisiko (risk control)(risk control)
HindariHindari (Risk avoid/ prevention) :(Risk avoid/ prevention) : tidaktidakmelakukanmelakukan aktifitasaktifitasygyg berisikoberisiko
ReduksiReduksi / Mitigation (Risk reduction :/ Mitigation (Risk reduction :
mereduksimereduksi atauatau meminimalkanmeminimalkan berulangnyaberulangnya atauataudampakdampakkejadiankejadian..
2.2. PembiayaanPembiayaan risikorisiko (Risk Financing(Risk Financing))
Transfer (Risk transfer):Transfer (Risk transfer): membagimembagi bebanbeban atauataurisikorisiko kekeAsuransiAsuransi,, kontrakkontrakkerjasamakerjasama, joint, joint
ventures,dllventures,dll
TerimaTerima (Risk acceptance / retention):(Risk acceptance / retention): beberapabeberaparisikorisiko mungkinmungkin minimalminimal dandan dptdpt diterimaditerima
RISK MAPPING
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S G
Impact vs. ProbabilityImpact vs. Probability
C o n t r o l
Sh a r e M i t i g a t e & Co n t r o l
A c c e p t
High Risk
Medium Risk
Medium Risk
Low Risk
High
I
M
PA
C
T
Low PROBABILITY High
www.coso.org
SARANSARAN--SARAN :SARAN :
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SOSIALISASIKAN KONSEP DAN PRINSIPSOSIALISASIKAN KONSEP DAN PRINSIP--PRINSIP RISKPRINSIP RISK
MANAGEMENTMANAGEMENT
BANGUN NETWORK ANTARA PIMPINAN DANBANGUN NETWORK ANTARA PIMPINAN DAN
DEPARTEMEN ATAU UNITDEPARTEMEN ATAU UNIT
DUKUNG IMPLIMENTASI PROGRAMDUKUNG IMPLIMENTASI PROGRAM--PROGRAMPROGRAM
MANAJEMEN RISIKOMANAJEMEN RISIKO
BANGUN TIM INTERDISIPLINER UNTUKBANGUN TIM INTERDISIPLINER UNTUK
IMPLEMENTASI DANMONITOR PROGRAM MANAJEMENIMPLEMENTASI DANMONITOR PROGRAM MANAJEMENRISIKORISIKO
PENDIDIKAN DAN PELATIHAN PADAPENDIDIKAN DAN PELATIHAN PADA
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PENDIDIKAN DAN PELATIHAN PADAPENDIDIKAN DAN PELATIHAN PADA
TINGKAT MANAJER DAN PELAKSANATINGKAT MANAJER DAN PELAKSANA
KEMBANGKAN STRATEGI UNTUKKEMBANGKAN STRATEGI UNTUK
IMPLEMENTASI RISK MANAGEMENTIMPLEMENTASI RISK MANAGEMENT
IMPLEMENTASIKAN PROSESIMPLEMENTASIKAN PROSES--PROSESPROSES
PENILAIANPENILAIAN
MONITOR EFEKTIFITAS DARI PROSESMONITOR EFEKTIFITAS DARI PROSESMANAJEMEN RISIKOMANAJEMEN RISIKO
KESIMPULANKESIMPULAN
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Those who do not learn from theirThose who do not learn from their
mistakes are condemned to repeat themmistakes are condemned to repeat them
We cannot change the human condition, butWe cannot change the human condition, but
we can change the conditions under whichwe can change the conditions under whichhumans work.humans work.
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