scholarly journals "PENTINGNYA PENCEGAHAN BAHAYA DAN ADVERSE EVENT SEBAGAI UPAYA MENJAGA KESELAMATAN PASIEN DI RUMAH SAKIT"

2020 ◽  
Author(s):  
Awina Milla Shilmy Sitorus
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Adverse Events ◽  
Near Miss

Rumah sakit adalah sarana pelayanan kesehatan yang dibutuhkan ketika seseorang sakit dan membutuhkan bantuan dengan tujuan untuk menyelamatkan kondisi pasien. Keselamatan Pasien (patient safety) merupakan sesuatu yang jauh lebih penting dari pada sekedar efisiensi pelayanan. Perilaku perawat dengan kemampuan perawat sangat berperan penting dalam pelaksanaan keselamatan pasien. Perilaku yang tidak aman, lupa, kurangnyaperhatian/motivasi, kecerobohan, tidak teliti dan kemampuan yang tidak memedulikan dan menjaga keselamatan pasien berisiko untuk terjadinya kesalahan dan akan mengakibatkan cedera pada pasien, berupa Near Miss (Kejadian Nyaris Cedera/KNC) atau Adverse Event (Kejadian Tidak Diharapkan/KTD) selanjutnya pengurangan kesalahan dapat dicapai dengan memodifikasi perilaku. Perawat harus melibatkan kognitif, afektif dan tindakan yang mengutamakan keselamatan pasien (Julia, 2016).Cahyono (2008) menyatakan setiap asuhan klinis baik terkait dengan proses diagnosis, terapi, tindakan pembedahan, pemberian obat, pemeriksaan laboratorium, dsb dapat menimbulkan kerugian yang tidak diharapkan pasien baik secara fisik (cedera iatrogenik), finansial, maupun sosial. Secara lebih populer, asuhan klinis yang kemudian menimbulkan dampak yang merugikan bagi pasien akibat manajemen medis dan bukan akibat penyakit yang diderita pasien dikenal sebagai adverse events atau KTD (baik oleh dokter maupun pasien).

scholarly journals Mencegah terjadinya adverse events dengan memberikan pendidikan kesehatan tentang peran pasien dan keluarga untuk mencegah terjadinya bahaya

2020 ◽  
Author(s):  
Indri Novita Magdalena Aruan
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Adverse Events ◽  
World Health Organization ◽  
Near Miss ◽  
World Health ◽  
Health Organization

Keselamatan Pasien (Patient Safety) merupakan sesuatu yang jauh lebih penting dari pada sekedar efisiensi pelayanan. Perilaku perawat dengan kemampuan perawat sangat berperan penting dalam pelaksanaan keselamatan pasien. Perilaku yang tidak aman, lupa, kurangnya perhatian/motivasi, kecerobohan, tidak teliti dan kemampuan yang tidak memperdulikan dan menjaga keselamatan pasien berisiko untuk terjadinya kesalahan dan akan mengakibatkan cedera pada pasien, berupa Near Miss (Kejadian Nyaris Cedera/KNC) atau Adverse Event (Kejadian Tidak Diharapkan/KTD) selanjutnya pengurangan kesalahan dapat dicapai dengan memodifikasi perilaku. Perawat harus melibatkan kognitif, afektif dan tindakan yang mengutamakan keselamatan pasien. World Health Organization (WHO), 2014 Keselamatan pasien merupakan masalah keseahatan masyarakat global yang serius.

scholarly journals Adverse Events in Home-Care Nursing Agencies and Related Factors: A Nationwide Survey in Japan

2021 ◽  
Vol 18 (5) ◽  
pp. 2546
Author(s):  
Noriko Morioka ◽  
Masayo Kashiwagi
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Adverse Events ◽  
Home Care ◽  
Process Of Care ◽  
Related Factors ◽  
Cross Sectional ◽  
Home Care Nursing ◽  
Number Of Patients ◽  
Care Nursing

Despite the importance of patient safety in home-care nursing provided by licensed nurses in patients’ homes, little is known about the nationwide incidence of adverse events in Japan. This article describes the incidence of adverse events among home-care nursing agencies in Japan and investigates the characteristics of agencies that were associated with adverse events. A cross-sectional nationwide self-administrative questionnaire survey was conducted in March 2020. The questionnaire included the number of adverse event occurrences in three months, the process of care for patient safety, and other agency characteristics. Of 9979 agencies, 580 questionnaires were returned and 400 were included in the analysis. The number of adverse events in each agency ranged from 0 to 47, and 26.5% of the agencies did not report any adverse event cases. The median occurrence of adverse events was three. In total, 1937 adverse events occurred over three months, of which pressure ulcers were the most frequent (80.5%). Adjusting for the number of patients in a month, the percentage of patients with care-need level 3 or higher was statistically significant. Adverse events occurring in home-care nursing agencies were rare and varied widely across agencies. The patients’ higher care-need levels affected the higher number of adverse events in home-care nursing agencies.

scholarly journals Menerapkan Kebijakan Untuk Keselamatan Pasien

2019 ◽  
Author(s):  
Eva Eryanti Harahap
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Medical Error ◽  
Near Miss

Keselamatan pasien itu sangat penting dan menjadi tuntutan bagi rumah sakit untuk melaksanakannya karena rumah sakit sangat berpotensi terjadinya risiko berupa kesalahan medis (medical error), kejadian yang tidak diharapkan (adverse event) dan nyaris terjadi (near miss). Untuk itu, , Kementerian Kesehatan Republik Indonesia telah menerbitkan Panduan Nasional Keselamatan Pasien (Patient Safety) di Rumah Sakit tahun 2008 yang terdiri dari 7 standar, yaitu: 1) hak pasien, 2) mendidik pasien dan keluarga, 3) keselamatan pasien dan kesinambungan pelayanan, 4) penggunaan metode peningkatan kinerja untuk melakukan evaluasi dan program, 5) peningkatan keselamatan pasien, 6)mendidik staf tentang keselamatan kerja, dan 7) komunikasi merupakan kunci bagi staf untuk mencapai keselamatan pasien. Dan agar tercapainya standar tersebut Panduan Nasional menganjurkan 7 Langkah Menuju Keselamatan Pasien Rumah Sakit, yaitu: 1) bangun kesadaran akan keselamatan pasien, 2) pimpin staf, 3) integrasikan aktivitas pengelolaan risiko, 4) kembangkan sistem pelaporan, 5) libatkan dan berkomunikasi dengan pasien, 6) belajar dari berbagai pengalaman tentang keselamatan pasien, dan 7) cegah cedera melalui implementasi sistem keselamatan pasien

scholarly journals PATIENT SAFETY SEBAGAI SISTEM PENCEGAH KTD DAN PENINGKATAN KUALITAS PELAYANAN RUMAH SAKIT

2019 ◽  
Author(s):  
Minda Ihsaniah Nasution
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Underlying Disease ◽  
Near Miss

Kesalahan yang terjadi dalam proses asuhan keperawatan akan berpotensi mengakibatkan cedera pada pasien, bisa berupa Near Miss atau Adverse Event (Kejadian Tidak Diharapkan/KTD).Adverse Event atau Kejadian Tidak Diharapkan (KTD) merupakan suatu kejadian yang mengakibatkan cedera yang tidak diharapkan pada pasien karena suatu tindakan (commission) atau tidak mengambil tindakan yang seharusnya diambil (omission), dan bukan karena “underlying disease” atau kondisi pasien.

scholarly journals Responding to adverse patient safety events in Viet Nam

2019 ◽  
Vol 19 (1) ◽  
Author(s):  
Reema Harrison ◽  
Anurag Sharma ◽  
Merrilyn Walton ◽  
Esmond Esguerra ◽  
Seinyenede Onobrakpor ◽  
...  
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Physical Health ◽  
Psychological Health ◽  
Health Professionals ◽  
Incident Reporting ◽  
Near Miss ◽  
Viet Nam ◽  
Organisational Support ◽  
Doctors And Nurses

Abstract Background The psychological and professional impact of adverse events on doctors and nurses is well-established, but limited data has emerged from low- and middle-income. This article reports the experiences of being involved in a patient safety event, incident reporting and organisational support available to assist health professionals in Viet Nam to learn and recover. Method Doctors and nurses (1000) from all departments of a 1500-bed surgical and trauma hospital in Viet Nam were invited to take part in a cross-sectional survey. The survey explored respondents’ involvement in adverse events and/or near miss, their emotional, behavioural and coping responses, experiences of organisational incident reporting, and the learning and/or other consequences of the event. Survey items also assessed the availability of organisational support including peer support and mentorship. Results Of the 497 respondents, 295 (59%) experienced an adverse event in which a patient was harmed, of which 86 (17%) resulted in serious patient harm. 397 (80%) of respondents experienced a near miss, with 140 of these (28%) having potential for serious harm. 386 (77%) reporting they had been affected professionally or personally in some way, with impacts to psychological health (416; 84%), physical health (388; 78%), job satisfaction (378; 76%) and confidence in their ability (276; 56%) commonly reported. Many respondents were unable to identify local improvements (373; 75%) or organisation-wide improvements following safety events (359; 72%) and 171 (34%) admitted that they had not reported an event to their organisation or manager that they should have. Conclusions Health professionals in Viet Nam report impacts to psychological and physical health as a result of involvement in safety events that reflect those of health professionals internationally. Reports of limited organisational learning and improvement following safety events suggest that patient safety culture is underdeveloped in Viet Nam currently. In order to progress work on patient safety cultures and incident reporting in Viet Nam, health professionals will need to be convinced not only that they will not be exposed to punitive action, but that learning and positive changes will occur as a result of reporting safety events.

Recognizing the Ordinary as Extraordinary: Insight Into the “Way We Work” to Improve Patient Safety Outcomes

2017 ◽  
Vol 26 (4) ◽  
pp. 272-277 ◽  
Author(s):  
Elizabeth A. Henneman
Keyword(s):  
Patient Safety ◽  
Adverse Events ◽  
Eye Tracking ◽  
Medical Errors ◽  
Improve Patient Safety ◽  
Safety Net ◽  
Near Miss ◽  
The Impact ◽  
Risk Processes ◽  
Insight Into

The Institute of Medicine (now National Academy of Medicine) reports “To Err is Human” and “Crossing the Chasm” made explicit 3 previously unappreciated realities: (1) Medical errors are common and result in serious, preventable adverse events; (2) The majority of medical errors are the result of system versus human failures; and (3) It would be impossible for any system to prevent all errors. With these realities, the role of the nurse in the “near miss” process and as the final safety net for the patient is of paramount importance. The nurse’s role in patient safety is described from both a systems perspective and a human factors perspective. Critical care nurses use specific strategies to identify, interrupt, and correct medical errors. Strategies to identify errors include knowing the patient, knowing the plan of care, double-checking, and surveillance. Nursing strategies to interrupt errors include offering assistance, clarifying, and verbally interrupting. Nurses correct errors by persevering, being physically present, reviewing/confirming the plan of care, or involving another nurse or physician. Each of these strategies has implications for education, practice, and research. Surveillance is a key nursing strategy for identifying medical errors and reducing adverse events. Eye-tracking technology is a novel approach for evaluating the surveillance process during common, high-risk processes such as blood transfusion and medication administration. Eye tracking has also been used to examine the impact of interruptions to care caused by bedside alarms as well as by other health care personnel. Findings from this safety-related eye-tracking research provide new insight into effective bedside surveillance and interruption management strategies.

scholarly journals Langkah- Langkah Menuju Budaya Keselamatan Pasien

2019 ◽  
Author(s):  
Monika Naulia Marina
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Literature Review ◽  
Medical Errors ◽  
Medical Error ◽  
Near Miss

AbstrakLatar belakang : Hampir setiap tindakan medic menyimpan potensi resiko. Banyaknya jenis obat, jenis pemeriksaan dan prosedur, serta jumlah pasien dan staf Rumah Sakit yang cukup besar, merupakan hal yang potensial bagi terjadinya kesalahan medis (medical errors). Artinya kesalahan medis didefinisikan sebagai: sLuatu Kegagalan tindakan medis yang telah direncanakan untuk diselesaikan tidak seperti yang diharapkan (yaitu., kesalahan tindakan) atau perencanaan yang salah untuk mencapai suatu tujuan (yaitu., kesalahan perencanaan). Tujuan : untuk mengetahui langkah-langkah menuju budaya keselamatan pasien. Metode : metode yang digunakan adalah literature review. Hasil : Kesalahan yang terjadi dalam proses asuhan medis ini akan mengakibatkan atau berpotensi mengakibatkan cedera pada pasien, bisa berupa Near Miss atau Adverse Event (Kejadian Tidak Diharapkan/KTD). Pembahasan : Kesalahan tersebut bisa terjadi dalam tahap diagnostic seperti kesalahan atau keterlambatan diagnose, tidak menerapkan pemeriksaan yang sesuai, menggunakan cara pemeriksaan yang sudah tidak dipakai atau tidak bertindak atas hasil pemeriksaan atau observasi. Penutup : Mempertimbangkan betapa pentingnya misi rumah sakit untuk mampu memberikan pelayanan kesehatan yang terbaik terhadap pasien mengharuskan rumah sakit untuk berusaha mengurangi medical error sebagai bagian dari penghargaannya terhadap kemanusiaan, maka dikembangkan system Patient Safety yang dirancang mampu menjawab permasalahan yang ada.

scholarly journals Pengetahuan perawat tentang keselamatan pasien

2020 ◽  
Author(s):  
Aswita Aprililian Sihaloho
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Near Miss

Patient Safety (keselamatan pasien) merupakan suatu sistem yang untuk meningkatkan mutu pelayanan kesehatan. bahwa setiap tindakan medis menyimpan potensi resiko. Banyaknya jenis obat, jenis pemeriksaan dan prosedur, serta jumlah pasien dan staf Rumah Sakit yang cukup besar terutama untuk tenaga perawat yang memiliki jumlah terbesar dalam jumlah kepegawaian rumah sakit, merupakan hal yang potensial bagi terjadinya kesalahan medis.Kesalahan medis merupakan sebagai suatu kegagalan tindakan medis yang sebelumnya telah direncanakan. Kesalahan yang terjadi dalam proses asuhan medis ini akan mengakibatkan atau cedera pada pasien, bisa berupa Near Miss atau Adverse Event (Kejadian Tidak Diharapkan/KTD). Tenaga perawat merupakan tenaga profesional yang berperan penting dalam fungsi rumah sakit. Hal tersebut didasarkan atas jumlah tenaga perawat sebagai porsi terbesar didalam pelayanan rumah sakit. Dalam menjalankan fungsinya, perawat merupakan staf yang memiliki kontak terbanyak dengan pasien. Perawat juga merupakan bagian dari suatu tim, yang didalamnya terdapat berbagai profesional lain seperti dokter. Luasnya peran perawat memungkinkannya terjadinya risiko kesalahan pelayanan. Hal-hal tersebut menempatkan peran perawat sebagai komponen penting dalam pelaporan kesalahan pelayanan dalam pengembangan program keselamatan pasien di rumah sakit.

Adverse Events and Patient Safety in the Operating Theatre: Perspectives of 549 Surgeons

2010 ◽  
Vol 92 (6) ◽  
pp. 1-4 ◽  
Author(s):  
C Pritchard ◽  
J Brackstone ◽  
J MacFie
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Adverse Events ◽  
Operating Theatre ◽  
Near Misses ◽  
The Uk

The Chief Medical Officer's recent report, 'Making surgery safer', was a response to widespread concern about patient safety in the operating theatre. Annually there are an estimated 129,416 'untoward events' in the UK. These range from 'near misses' (NM), in which a patient is 'nearly harmed', to an 'adverse event' (AE), usually defined as 'an unintended injury or complication, including death'.

Effectiveness of systems changes suggested by simulation of adverse surgical outcomes

2015 ◽  
Vol 1 (3) ◽  
pp. 83-86 ◽  
Author(s):  
Meghan E Garstka ◽  
Douglas P Slakey ◽  
Christopher A Martin ◽  
Eric R Simms ◽  
James R Korndorffer
Keyword(s):  
Adverse Event ◽  
Patient Safety ◽  
Adverse Events ◽  
Surgical Outcomes ◽  
Improve Patient Safety ◽  
Healthcare Systems ◽  
Adverse Outcomes ◽  
Cause Analysis ◽  
Root Cause ◽  
Improve Patient

BackgroundSimulation of adverse outcomes (SAO) has been described as a technique to improve effectiveness of root cause analysis (RCA) in healthcare. We hypothesise that SAO can effectively identify unsuspected root causes amenable to systems changes.MethodsSystems changes were developed and tested for effectiveness in a modified simulation, which was performed eight times, recorded and analysed.ResultsIn seven of eight simulations, systems changes were effectively utilised by participants, who contacted anaesthesia using the number list and telephone provided to express concern. In six of seven simulations where anaesthesia was contacted, they provided care that avoided the adverse event. In two simulations, the adverse event transpired despite implemented systems changes, but for different reasons than originally identified. In one case, appropriate personnel were contacted but did not provide the direction necessary to avoid the adverse event, and in one case, the telephone malfunctioned.ConclusionsSystems changes suggested by SAO can effectively correct deficiencies and help improve outcomes, although adverse events can occur despite implementation. Further study of systems concepts may provide suggestions for changes that function more reliably in complex healthcare systems. The information gathered from these simulations can be used to identify potential deficiencies, prevent future errors and improve patient safety.

Sign in / Sign up

Export Citation Format

Share Document