CONTRIBUTION OF PHARMACY EDUCATION IN PROMOTING PATIENT SAFETY AT RSHS

RIWAYAT HIDUP • • • • • • • • •

NAMA Pangkat / Gol Tempat Tgl Lahir Jabatan Pendd

: : : : :

Dr. H.BAYU WAHYUDI, MPHM, SpOG Pembina Utama Madya / IV D Jakarta, 1 Maret 1962 Direktur utama RSUP Dr.HASAN SADIKIN BANDUNG 1. FK Unsri ( Dokter Umum) 2. AIHD Mahidol Univ Bangkok (MPHM) Fellows WHO 3. FK Unsri ( Spesialis Obgin) 4. On Going : Doktoral (Candidate) FK Unpad MHKes ( Unika Soegiya Pranata)

• • • • • • • •

Pekerjaan : 1. Ka Puskesmas transimigras Air Sugihan Jalur 27 & Jalur 25 OKI SumSel 2. Pimp Proyek PKLP Kanwil Prov.Sumsel 3. Dokter Fungsional Obgin RSUD Liwa Lampung Barat 4. Koord Executive UNFPA (Kanwil Prop. Sumsel ) 5. Direktur RS Kusta dr.Rivai Abdulah Palembang (RSSK) 6. Direktur Medik & Keperawatan RSUP dr.M.Hoesin (RSMH) Palembang 7. Direktur Utama RSUP dr.Moh.Hoesin (RSMH) Palembang 8. Direktur Utama RSUP dr. Hasan Sadikin (RSHS) Bandung

CONTRIBUTION OF PHARMACY EDUCATION IN PROMOTING PATIENT SAFETY AT RSHS The 3rd Asia Pacific Pharmacy Education Workshop School of Pharmacy ITB Bandung, 20 t h November 2012 Bayu Wahyudi (President Director RSUP Dr.Hasan Sadikin Bandung)

Introduction • Reports from the IOM (Institute of Medicine) 1999: - At least 44,000 patients died in hospital within a year due to medical errors that could have been prevented. - This quantity exceeds deaths due to traffic accidents, breast cancer and AIDS. • In pharmaceutical research Bates (JAMA, 1995) shows that the highest levels of medication errors: - Ordering stage (49%) - Management administration (26%) - Pharmacy management (14% ) - Transcribing (11%). SSM/SH

• Reports National Patient Safety Incident (Persatuan Rumah Sakit Indonesia / IMHA Congress, Sep 2007); Errors in drug administration was ranked first (24.8%) of the 10 major incidents. • Research at RSHS / HSGH (2002) ; Potential error in pharmacy process: 0.26% SSM/SH

STATUS HSGH Government-owned Hospital Under and directly responsible to the Directorate General of Heatlh Care, Ministry of Health Class A Hospital Teaching Hospital Top Referral Hospital for West Java Province National Center of Excellence for Nuclear Medicine The only Educational Center for Nuclear Medicine Specialist in Indonesia

Iso 9001- 2008

RSUP Dr.Hasan Sadikin Bandung

Jalan Pasteur No. 38 Bandung telephone.62-022-2034953/57 Fax.62-022-2032216

MISSION

VISION To Be a World Class Indonesian Hospital Excelling In Health Services, Education & Research Menjadi Rumah sakit Indonesia Kelas Dunia yang Unggul dalam Pelayanan, Pendidikan dan Penelitian

To Provide Comprehensive and Excellent Services Integrated with Education and Research Melaksanakan Pelayanan Kesehatan Paripurna dan Prima yang Terintegrasi dengan Pendidikan dan Penelitian

MOTTO

VALLUE Professional, Respect, Integrity, Humanistic, Realtives Profesional Respek Integritas Manusiawi Amanah

Your Health is Our Priority Kesehatan Anda Menjadi Prioritas Kami

RSUP Dr.Hasan Sadikin Bandung


OBJECTIVES  To provide standardized integrated-health services focusing on the customer satisfaction which have regional competitive advantage.  To materialize HSGH as a model of teaching hospital in Indonesia.  To materialize HSGH as a research based hospital  To increase the hospital cost recovery as the effort to be a self financing hospital

Dr.Hasan Sadikin General Hospital

Jalan Pasteur No. 38 Bandung West Java Indonesia Phone.62-022-2034953/57 Fax.62-022-2032216

STAFF STRENGTH February, 2012

Strategic Staff 447 (14%)

Security 22 (1%)

Administration 447 (14%)

Dental Specialist 33 (1%) General Dentist 15 (1%)

General Physician 42 (1%) Medical Specialist; 365; 11%

Medical Specialist General Physician Dental Specialist General Dentist Nurse Widwife Paramedics

Non Health Functional Staff 18 (1%) Paramedics 574 Widwife (18%) 94 (3%)

Non Health Functional Staff Administration Strategic Staff Nurse 1130 (35%)

Total: 3.187 staff

OUT PATIENT DEPARTMENT • 20 specialty clinics and 16 Excellent clinics specialist , for 127 subspecialties for regular patients located in the Out-patient Department ( 2.000 – 3.000 patient/ day) OPD 2

28 specialist clinics for executive class located in the Anggrek Building Number of OPD Visit Years 2001 to 2011 700.000 600.000

580.535 527.771 557.346

510.097

500.000 400.000

551.321

Registration Counter

403.216 367.798 344.542

300.000

332.459 298.160

304.333

200.000 100.000

20 11

20 10

20 09

20 08

20 07

20 06

20 05

20 04

20 03

20 02

20 01

0



SPECIALIST CLINIC

Laboratory

Waiting Room Level 2

Information Service

Pharmacy



Radiology

Waiting Room Level 1

In Patient Department BED CAPACITY BY CLASSES Dr. HASAN SADIKIN GENERAL HOSPITAL NO

CLASSES

NUMBER

%

1.

VIP

121

11,00

2.

CLASS I

107

9,73

3.

CLASS II

137

12,45

4.

CLASS III (POOR PATIENT)

650

59,09

5.

Intensive (GICU, ICCU, PICU,NICU)

35

3,18

6.

High Care Unit + Radio Therapy + Nucl. Nucl. Med + Isolation Ward

50

4,54

Total

1.100

100,00

Medical Wards

VIP Wards Dr.Hasan Sadikin General Hospital


Ingat UU 44/2009 Rumah Sakit sebagai suatu sistem, dengan Manajemen sebagai representatif atau penanggungjawab Pasal 46 • Rumah Sakit bertanggung jawab secara hukum terhadap semua kerugian yang ditimbulkan atas kelalaian yang dilakukan oleh tenaga kesehatan di Rumah Sakit. RSUP Dr.Hasan Sadikin Bandung


Penjelasan ps 36 UU 44/2009 Tata kelola rumah sakit yang baik adalah penerapan fungsi-fungsi manajemen rumah sakit yang berdasarkan prinsip-prinsip transparansi, akuntabilitas, independensi dan responsibilitas, kesetaraan dan kewajaran. Tata kelola klinis yang baik adalah penerapan fungsi manajemen klinis yang meliputi kepemimpinan klinik, audit klinis, data klinis, risiko klinis berbasis bukti, peningkatan kinerja, pengelolaan keluhan, mekanisme monitor hasil pelayanan, pengembangan profesional, dan akreditasi rumah sakit. RSUP Dr.Hasan Sadikin Bandung


RSHS BANDUNG

ONE TEAM, ONE VISION, ONE GOAL

Harus dapat hidup , Harus dpt m’layani Masyarakat Harus Profesional, Harus mandiri Harus dapat bersaing ,Harus dapat berkembang

WORLD CLASS HOSPITAL (JCI) 2012-13 HEALTH TOURISM STANDAR PELAYANAN

PADAT KARYA, - PADAT SDM, - PADAT TEKNOLOGI, - PADAT MODAL - PADAT MASALAH

PATIENT SAFETY PATIENT SATISFACTION

WTP RS Pendd TOGETHERNESS BLU

PENINGKATAN SDM INFRA STRUKTUR SARANA PRASARANA

SABILULUNGAN SAUYUNAN, SAPIHANEAN SABANDA SARIKSA

KEMKES + KEMDIKNAS+ PEMDA + NGO + MASYARAKAT

RISET

PENDIDIKAN

•Peningkatan produktivas •Mutu pelayanan RS (PATIENT SATISFACTION) •Keselamatan pasien (PATIENT SAFETY) •Hukum + Kesejahteraan

menjadi RSI kelas dunia melalui akred internasional JCI

15

PERCEPATAN REFORMASI BIROKRASI DLM RANGKA MENINGKATKAN DAYA SAING RSHS

BERGESERNYA POLA MANAJEMEN RUMAH SAKIT UPAYA

DULU

SEKARANG KESELAMATAN PASIEN (PATIENT SAFETY)

MELAYANI PASIEN

PROFIT, UNTUK HIDUP DAN TUMBUH BERKEMBANG

MELAKSANAKAN KEGIATAN

EFFISIEN , INTERPREUNER KEPUASAN PASIEN (PATIENT SATISFACTION)

MINTA DAN HABISKAN ANGGARAN ATURAN BIROKRASI MEMBELENGGU

KELELUASAAN MENGATUR (BERBASIS KINERJA) FLEKSIBEL JCI

JOINT COMMISSION INTERNATIONAL

7 K = (KOTOR, KUMEL, KODOL, KUDEL KUMUH, KESET, KLELERAN, KEJAM)

PELAYANAN OPTIMAL (EXCELLENCE SERVICE QUALITY) KESEJAHTERAAN

JENIS KESALAHAN (TYPE of ERRORS) DIAGNOSTIC ERROR:    

Kesalahan atau keterlambatan membuat diagnosis. Tidak menggunakan tes yang diindikasikan. Menggunakan tes yang sudah ketinggalan zaman. Tidak bertindak terhadap hasil atau monitoring tes. TREATMENT ERROR:    

Kesalahan dalam proses kerja, prosedur atau tes. Kesalahan memberikan terapi. Kesalahan dosis atau cara memberikan obat. Keterlambatan (yang dapat dicegah) utk memberikan terapi atau merespon hasil abnormal suatu tes.  Melakukan perawatan tak benar /tak ada indikasi

KESALAHAN PENCEGAHAN (PREVENTIVE ERROR):

 Tidak menyediakan prophylactic treatment.  Tidak cukup melakukan monitoring atau follow-up terhadap terapi / tindakan yang telah diberikan. KESALAHAN LAIN  Kegagalan komunikasi.  Kegagalan peralatan (equipment failure).  Kegagalan dari sistem-sistem lainnya. Leape et al, Quality Review Bulletin, 1993

Situation

SSM/SH

Defini Definition tion

(menurut US Pharmacopoeia)

:

“any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of health care professional, patient, or consumer. Such events may be related to professional practice, health care products, procedures, and systems, including prescrebing; order communication; product labeling, packaging, and nomenclature; compounding; dispensing; distribution; administration; education; monitoring; and use”

SSM/SH

SAFETY IS A CULTURE: SA F E T Y C U LT U R E B L A M E F R E E C U LT U R E R R E P O R T I N G C U LT U R E L EA R N I N G C U LT U R E

EDUCATION SSM/SH

Situation

SSM/SH

PREVENTION IS STILL THE BEST DEFENS AGAINST THE ACCUSATION OF MALPRACTICE. (Morris, Moritz)

DRUG PROCESS TO THE PATIENT Selection & Procurement

Monitoring

Storage

Administration

Ordering and Transcribing

Preparing and Dispensing

MANAGING MEDICATION ERROR • Necessary corrective and supportive therapy • Documented and reported • Gathering fact and investigation (for significant errors) • Review and prevented way • Information about medication error, educational tool for staf, disciplinary action • Supervisor • Reported to national monitoring program

METHODS USED TO MINIMIZE MEDICATION ERROR Forcing functions and constrains Most Effective

Automation and computerizations Standardization and protocols Checklists and double check Systems Rules and policies

Least Effective

Education/information Be more careful, be vigilant

QUALITY ASSURANCE: JCI ACCREDITATION

SSM/SH

Standar Akreditasi JCI Patient Centered Standards

Health care organization management standards

1. International Patient Safety Goals (IPSG) 2. Access to Care and Continuity of care (ACC) 3. Patient and Family Rights (PFR) 4. Assessment of Patients (AOP) 5. Care of Patients (COP) 6. Anesthesia and Surgical Care (ASC) 7. Medication Management and Use (MMU) 8. Patient and Family Education (PFE)

1. Quality improvement and Patient Safety (QPS) 2. Prevention and Control of Infections (PCI) 3. Governance, Leadership, and Direction (GLD) 4. Facility Management and Safety (FMS) 5. Staff Qualifications and Education (SQE) 6. Management of Communication and Information (MCI) 28

JCI-standar akreditasi internasional Standar 14 buah • Standar berfokus pasien 8 buah • Standar berfokus manajemen 6 buah

Elemen :1214 • • • • • • •

IPSG :23 ACC : 104 AOP : 184 COP : 74 ASC : 51 MMU : 82 PFE : 27

QPS; 88 PCI : 83 GLD : 98 FMS : 92 SQE : 99 PFE : 27 MCI : 109

ADVERSE EVENT STANDAR LAYANAN TIDAK TERPENUHI

STANDAR LAYANAN TERPENUHI

DIRECT CAUSATION

RISIKO MEDIK

UNFORESEEN RISK (tdk diduga) BUKAN MAL PRAKTEK

DAMAGES FORESEEN RISK (diduga)

Melakukan ANTISIPASI

Tanpa ANTISIPASI

MALPRAKTEK DAMAGES DIRECT CAUSATION

SISTEM PELAPORAN KEJADIAN (INCIDENT REPORT SYSTEM) di Rumah Sakit ( RSHS ) • • • •

Untuk Iaporan dan evaluasi Sebagian dari Critical Risk Management Untuk perkecil risiko utk pasen dan petugas Untuk kepentingan yang berhubungan dengan aspek hukum

Kegiatan Keselamatan Pasen Rumah Sakit • 7 Langkah Keselamatan pasen RS • Membuat Pedoman Keselamatan Pasen RS sesuai akreditasi • Pertemuan rutin Pengayaan pada anggota Keselamatan Pasen RS • Sosialisasi kegiatan Program Keselamatan pasen RS • Laporan Insiden Keselamatan Pasien • (Membuat SMS Hotline Patient Safety RSHS : 081220050547)

STORAGE

SSM/SH

HIGH ALERT MEDICATION Look alike Sound alike (LASA)

High Concentrate Solution SSM/SH

MEDICATION ORDER REVIEW

SSM/SH

DRUG INFORMATION

MEDIA OF INFORMATION

Patient and Family Education

SSM/SH

DRUG COUNSELING To catch: 1. Right Patient 2. Right Indication 3. Right Medicine 4. Right Dose 5. Right Route of Administration 6. Right Time 7. Right Information

Patient compliance Goal of theraphy

SSM/SH

Quality of Life

THERAPY DRUG MONITORING

To Prevent Drug Related Problems (DRP’s)

SSM/SH

CLINICAL PHARMACY ACTIVITY Dosis ganda Dosis tidak jelas Dosis tidak lazim

17,7

Dosis tidak sama Duplikasi generik

DUPLICATION OF GENERIC NAME

Duplikasi Terapi Lama pemberian tidak tepat Obat tanpa indikasi

24,1

OVER DOSAGE

DUPLICATION OF DRUG THERAPHY Order obat tidak jelas: salah obat Over Dosis 30,4

Polifarmasi Salah signa

SSM/SH

Sub Dosis

Manfaat penerapan Sistim Keselamatan pasien RS 1. 2. 3. 4. 5. 6. 7.

Budaya safety meningkat & berkembang Komunikasi dengan pasen berkembang KTD menurun, dan peta KTD selalu ada dan terkini Risiko klinis menurun Keluhan dan ligitasi berkurang Mutu pelayanan meningkat Citra RS dan pelayanan meningkat, diikuti kepercayaan diri meningkat

KESIMPULAN

IMPROVE THE SAFETY - GOOD OUT COME

Lakukan Analysis – Man – Machine – Materials – Method – Money – Marketing

: dokter, perawat, nonmedis : alat terawat, dikalibrasi, SPO cara penggunaan, merk. : BMHP/obat, labeling, barr code, standar warna/ gambar. : informed consent, SOP, report, audit , monitor. : bayar, asuransi, subsidi : Promosi, Pencegahan

PRINSIP-PRINSIP MERANCANG SISTEM YANG AMAN (SAFETY SYSTEM ) di Rumah Sakit 1. Provide Leadership. 2. Ingat ada keterbatasan manusia dalam membuat desain. 3. Pikirkan bagaimana tim akan bekerja efektif . 4. Antisipasi hal-hal yang tidak dapat diduga. 5. Mempelajari keadaan lingkungan sekitar.

7 Langkah menuju Keselamatan Pasen RS 1. 2. 3. 4. 5. 6.

Bangun kesadaran akan nilai keselamatan pasen Pimpin dan dukung staf anda Integrasikan aktivitas pengelolaan risiko Kembangkan sistim pelaporan Libatkan dan berkomunikasi dengan pasen Belajar dan berbagi pengalaman tentang keselamatan pasen 7. Cegah cedera melalui implementasi keselamatan pasen

9 Langkah Solusi Keselamatan Pasen RS 1. 2. 3. 4. 5. 6. 7. 8. 9.

Perhatikan nama obat, rupa & ucapan mirip Pastikan Identifikasi Pasen Komunikasi secara benar saat serah terima/operan pasen Pastikan yang benar pada tubuh sisi yang benar Kendalikan cairan elektrolit pekat Pastikan akurasi pemberian obat pada pengalihan pelayanan Hindari salah kateter dan salah sambung slang Gunakan injeksi sekali pakai Tingkatkan kebersihan tangan untuk mencegah infeksi nosokomial

?

SAFETY AND SATISFACTION FOR ALL …!!

COMING TOGETHER, IS A BEGINNING WORKING TOGETHER, IS A PROGRESS KEEPING TOGETHER, IS A SUCCESS RSUP Dr.Hasan Sadikin Bandung


HATUR NUHUN

CONTRIBUTION OF PHARMACY EDUCATION IN PROMOTING PATIENT SAFETY AT RSHS

Recommend Documents