ADVERSE EVENT (kejadian tidak diharapkan) (KTD) Wirsma Arif Harahap Surgical Oncologist
PRIMUM, NON NOCERE FIRST, DO NO HARM
HIPPOCRATES’S TENET (460-335 BC)
What I want to talk about
“Freedom from accidental injury due to medical care, or medical errors” – Institute of Medicine 1999
What I want to talk about A
story How common is adverse event? Why does it happen? How should we think ? How should we respond?
“Mistakes are a fact of life.
It’s the response to the error that counts” - Nikki Giovanni
Florida Annual Accidental Deaths, 2003 5000 4500 4000 3500 3000 2500 2000 1500 1000 500 0
Deaths
Medical
Auto
Workplace
Air
5th leading cause
9th leading cause
How hazardous is health care? REGULATED
DANGEROUS (>1/1000)
Health Care
100,000
ULTRA-SAFE (<1/100K)
Driving Total lives lost per year
10,000
1,000
Chartered Flights
100
Mountain Climbing
10
Bungee Jumping
Scheduled Airlines
Chemical Manufacturing
European Railroads Nuclear Power
1 1
10
100
1,000
10,000
100,000
1,000,000 10,000,000
Number of encounters for each fatality Note: both dimensions are logarithmic
DATA KASUS DUGAAN MALPRAKTIK YANG SUDAH DILAPORKAN Tgl
Korban
Terlapor
Kasus
Lapor
1. 12 -02-04
Alm. Lucy Maywati RS Bersalin YPK Jkt
Meninggal saat melahirkan caecar
Polda Metro Jaya
2. 23-04-04
Wulan Yulianti
RSCM Jkt
Meninggal krn operasi pd usus
Polda Metro Jaya
3. 28 -04-04
Alm Lucy Maywati
RS Bersalin YPK Jkt
Penggelapan M/R
Polda Metro Jaya
4. 07-06-04
Jeremiah
RS Budi Lestari Bks RS Hermina, Bekasi
Operasi caecar mengakibatkan luka & cacat
Polda Metro Jaya
5. 11 -06-04
Mindo Sihombing
RS Persahabatan Jkt
Gagal operasi hernia
Polda Metro Jaya
6. 15-06-04
Anissa Safitri
RSCM Jkt
Hidrocepalus
Polda Metro Jaya
7. 24 -06-04
Alm. Jajang
RSUD Sukabumi Jabar Wabah malaria di Sukabumi
Polda Jawa Barat
8. 30-06-04
Alm. Lucy Maywati
RS Bersalin YPK Jkt
Polda Metro Jaya
9. 07 -07-04
Robinson L. Tobing RS Kodam Bkt Barisan Vegetativ State akibat operasi/ Medan cacat permanen
Meninggal saat melahirkan
Polda Sumatra Utara
10. 12-07-04
Anissa Safitri
Yayasan Amal Beduli Seribu, Jkt
Perbuatan tdk menyenangkan krn memulangkan pasien
Polda Metro Jaya
11. 08 -07-04
Ngatmi
RS Persahabatan Jkt
Operasi kanker payudara
Polda Metro Jaya
12. 14-07-04
Rohati
RS Darmais Jkt
Meninggal dunia akibat gagal operasi kanker payudara
Polda Metro Jaya
13. 18 -07-04
Dr Jane P
PT Newmont Minahasa Pencemaran limbah B3 Raya, Sulawesi Utara
Mabes Polri
14. 18-07-04
Srifika Modeong
RS CM & RS MMC Jkt
Keracunan mercury & arsen
Mabes Polri
15. 18 -07-04
Rasyid Rahman
RS CM & RS MMC Jkt
Keracunan mercury & arsen
Mabes Polri
16. 18-07-04
Juhria Ratubahe
RS CM & RS MMC Jkt
Keracunan Mercury & arsen
Mabes Polri
17. 18 -07-04
Masna Stiman
RS CM & RS MMC Jkt
Keracunan mercury & arsen
Mabes Polri
18. 26-07-04
Revy Anastasia
RS Cikini Jkt
Keracunan Obat
Polda Metro Jaya
19. 09 -07-04
Revy Anastasia
Apotik RS Cikini Jkt
Keracunan Obat
Polda Metro Jaya
20. 12-08-04
Rasyid Rahman
Menkes Ahmad Sujudi Pencemaran nama baik dgn Mabes Polri Mentamben P Yusgiantoro menyatakan tdk ada pencemaran Men LH Nabiel Makarim
21. 18 -08-04
Fellina Azzahra
RS Karya Medika Jkt
Meninggal krn salah operasi usus
Polda Metro Jaya
22. 31-08-04
Again Isna Nauli
RS Islam Bogor
Kelalaian medis yg berakibat cacat permanen
SATGA OPS Polda Jawa Barat
23. 03 -09-04
Anggi & Anggeli
RSCM Jkt
Membiarkan pasien yg hrs dirawat
Polda Metro Jaya
24. 03-09-04
Andreas
RS Pasar Rebo Jkt
Kelahiran yg mengakibatkan cacat
Polda Metro Jaya
25. 03 -09-04
Maena Nurrocmah RS Setia Mitra Jkt
Operasi usus
Polda Metro Jaya
26. 15-09-04
Fellina Azzahra
RS K Medika Cibitung RSCM Jkt
Meninggal krn operasi usus
Polda Metro Jaya
27. 16-09-04
Leonardus W Pete
RS Silom Gleaneglas
Penyaderaan krn tdk mampu byr
Polda Metro Jaya
28. 27-09-04
Wino Wiran
Polres Sorong Papua
Penganiayaan mengakibatkan mata dan dada rusak parah
Mabers Polri
29. 28-09-04
Lexyano Hamsalim RS Medistra Jkt
Infeksi akibat operasi klip jantung
Polda Metro Jaya
30. 28-09-04
Parrel Davin H.A Sinurat
RS Eva Sari Rawamangun Jkt
Lalai mengakibtakan org lain meninggal
Polda Metro Jaya
31. 05-10-04
Rizka Hudha
RS Harapan Bunda Jkt Lalai mengakibatkan kematian
Polda Metro Jaya
32. 05-10-04
Masita Ariani (Annisa)
Klinik Bedah Plastik Bandung
Kegagalan bedah plastik pd hidung
Dit Reskrim Polda Jawa Barat
33. 07-10-04
Tyava Putra Juliarty Klinik Dharma Bakti 2 RS harapan Kita Jkt
Keracunan obat mengakibatkan Steven Johnson Syndrom
Polda Metro Jaya
34. 20-10-04
Chealfiro M.P
RSCM Jkt
Operasi Hemia
Polda Metro Jaya
35. 20-10-04
Sahat Parulian
RS Cikini Jkt
Pencemaran nama baik
Polda Metro Jaya
36. 06-11-04
Fatimah
RSCM Jkt
Kelalaian mengakibatkan kematian
Polda Metro Jaya
37. 10-11-04
Panca Satriya Hasan Kesuma
Dr. Siti Fadillah S (Menkes RI)
Dugaan tindak pidana membuat perasaan tdk menyenangkan
Mabes Polri
38. 14-01-05
Siti Zulaeha
RSUD Pasar Rebo Jkt
Kesalahan dlm operasi
Polda Metro Jaya
39. 16-02-05
Selli Wane Carolina RS Fatmawati Jkt
Kesalahan dlm operasi pd tulang belakang berakibat cacat
Polda Metro Jaya
40. 24-02-05
Martha Manulang
RS St Carolus Jkt
Salah obat
Polda Metro Jaya
41. 11-03-05
Chris
RS Sumber Waras Jkt Kesalahan dlm operasi RS Mitra Kemayoran Jkt
Polda Metro Jaya
42. 11-03-05
Tumi
RS Harun Jkt
Kesalahan dlm operasi
Polda Metro Jaya
43. 11-03-05
Erwin Said
dr. GW Sp.B
Pelaku tanpa seizin korban mengambil ginjal korban
SIAGA OPS Bandar Lampung
44. 12-05-05
Royke Bagalutu, SH Rosyid Rusdi Sandino Brata (Asisten I Sukabumi)
Melarang membawa anak ke RS Hasan Sadikin Bandung
SATGAS OPS Jabar
45. 26-05-05
Royke Bagalatu, SH PT BIO FARMA Indo
Pemberian vaksin polio yg tdk diakui WHO
SATGAS OPS Jabar
46. 12-06-05
Nabila
Ka Dinkes Jabar Anaknya kejang2, panas berak2 Dinkes Depok setelah imunisasi polio, kmd Menkes RI meninggal PT Bio Farma Indonesia
Polda Metro Jaya
47. 18 -06-05
Wagirin
RS Pelabuhan
Polda Metro Jaya
BUHAROYAN NADAPDAP SH
Kelalaian Medis
Sumber : Dari berbagai sumber
Similar Vials: Cefazolin (antibiotic) and Vecuronium (paralyzing agent)
Acceptable? Health care is a highly complex, error prone industry. Medicine is not a hard science … combination of art and practice Aviation and Nuclear arms = High Reliability Organizations – strong safety record Wasn’t always like that….
Swiss Cheese Model of Accident Causation Goal Conflicts and Double Binds Incomplete Procedures
Mixed Messages Production Pressures Regulatory Responsibility Narrowness Shifting
Inadequate Training
Deferred Maintenance Attention Distractions
Clumsy Technology
LATENT FAILURES
Triggers
The World
Accident DEFENSES
Modified from Reason, 1991 © 1991, James Reason
KESALAHAN MEDIS (Medical Error)
Kesalahan yang terjadi dalam proses asuhan medis yang mengakibatkan atau berpotensi mengakibatkan cedera pada pasien. (KKP-RS)
Medical errors are associated with
inexperienced clinicians, new procedures,
extremes of age, complex care and urgent care. Poor communication, improper documentation, illegible handwriting, inadequate nurse-to-patient ratios, and similarly named medications are also known to contribute to the problem. Patient actions may also contribute
significantly to medical errors.
Example for M Error
Misdiagnosis Giving the wrong drug or (wrong patient, wrong chemical, wrong dose, wrong time, wrong route) Giving two or more drugs that interact unfavorably or cause poisonous metabolic byproducts Wrong site surgery such as amputating the wrong limb
Defenition Adverse effect is a harmful and undesired effect resulting from a medication or other intervention
KEJADIAN TIDAK DIHARAPKAN (KTD)/ Adverse Event
Suatu kejadian yang mengakibatkan cedera yang tidak diharapkan pada pasien karena suatu tindakan (commission) atau karena tidak bertindak (ommision), dan bukan karena “underlying disease” atau kondisi pasien (KKP-RS).
Adverse effects of medical procedures
Surgery may have a number of
undesirable or harmful after effects, such as infection, hemorrhage,
inflammation, scarring,
high intensity radiotherapy may cause burns and alterations in the skin.
Adverse effects of drugs
Drug interaction
Drug safety
Dose
Iatrogenesis is almost exclusively
used to refer to a state of ill health or adverse effect or complication caused by or resulting from medical treatment.
Side-effect" (when judged to be secondary to a main or therapeutic effect) and may result from an unsuitable or incorrect dosage or procedure
Complication, in medicine, is an
unfavorable evolution of a disease, a health condition or a medical treatment.
Medical malpractice is an act or omission by a health care provider which deviates from accepted standards of practice in the medical community and which causes injury to the patient. Simply put, medical malpractice is professional negligence (by a healthcare provider) that causes an injury.
A near miss is an unplanned event
that did not result in injury, illness, or damage - but had the potential to do so.
NYARIS CEDERA (NC)/ Near Miss
Suatu kejadian akibat melaksanakan suatu
tindakan (commission) atau tidak mengambil tindakan yang seharusnya diambil (omission), yang dapat mencederai pasien, tetapi cedera serius tidak terjadi, karena :
“keberuntungan”(mis.,pasien terima suatu obat kontra indikasi tetapi tidak timbul reaksi obat) “pencegahan” (suatu obat dengan overdosis lethal akan diberikan, tetapi staf lain mengetahui dan membatalkannya sebelum obat diberikan) “peringanan” (suatu obat dengan over dosis lethal diberikan, diketahui secara dini lalu diberikan antidotenya).(KKP-RS)
Pasien tidak cidera
Near Miss (NM) - Dpt obat “c.i.”, tdk timbul (chance) - Plan, diket, dibatalkan (prevention) - Dpt obat “c.i.”, diket, beri anti-nya (mitigation)
Medical Error
Pasien cidera
Adverse Event (AE) (KTD=Kejadian Tdk Diharapkan)
Proses of Care (Non Error) Nico A. Lumenta/KKP-RS
Pasien cidera
Adverse Event
Why do errors happen? All humans make errors: indeed, “the ability to make mistakes” allows human beings to function Most of medicine is complex and uncertain Most errors result from “the system” Healthcare has not tried to make itself safe
How to think of error?
An individual failing
Only the minority of cases amount from negligence or misconduct; so it’s the “wrong” diagnosis Doctors will hide errors May destroy many doctors inadvertently (the second victim)
A systems failure
This is the starting point for redesigning the system and reducing error
How to respond? Tactics Reduce complexity
Optimise information processing checklists, reminders, protocols Automate wisely Use constraints for instance, with needle connections Mitigate the unwanted side effects of change with training, for example.
The Pathway to Increased Patient Safety
Event Reporting Tool
Healthcare Incident Investigation Team
Data Analysis Cultural & Process Change
Performance Improvement Projects
Questions?
