03. Patient Safety is a Key Component of Risk Management - Dr. Adib a Yahya

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CURRICULUM VITAECURRICULUM VITAE DATA PRIBADIDATA PRIBADI

Nama : Nama : dr.ADIB ABDULLAH YAHYA,MARSdr.ADIB ABDULLAH YAHYA,MARSPangkat : Brigjen TNI (Purn)Pangkat : Brigjen TNI (Purn)Tempat/tanggal lahir : Magelang,16 Februari 1949Tempat/tanggal lahir : Magelang,16 Februari 1949

Jabatan : Jabatan : President Asian Hospital Federation (AHF)President Asian Hospital Federation (AHF) Agama : IslamAgama : IslamALAMAT : Jl. Punai H-24,Kel.Tengah,Jakarta Timur – 13540ALAMAT : Jl. Punai H-24,Kel.Tengah,Jakarta Timur – 13540

Telp : (021)8404580Telp : (021)8404580 Fax : (021) 8408047 Fax : (021) 8408047

HP : HP : 08161803497 08161803497

E-MAIL : E-MAIL : [email protected]@yahoo.com

PENDIDIKAN UMUMPENDIDIKAN UMUM

SMA Negeri Magelang 1966SMA Negeri Magelang 1966S1 : Fakultas Kedokteran Universitas Gajah Mada (UGM), S1 : Fakultas Kedokteran Universitas Gajah Mada (UGM),

Yogyakarta, 1973Yogyakarta, 1973S2 : Fakultas Kesehatan Masyarakat, Universitas Indonesia (UI), Jakarta, S2 : Fakultas Kesehatan Masyarakat, Universitas Indonesia (UI), Jakarta,

Program Kajian Administrasi Rumah Sakit ( KARS )Program Kajian Administrasi Rumah Sakit ( KARS )

PENDIDIKAN MILITERPENDIDIKAN MILITER

Sekolah Staf dan Komando TNI Angkatan Darat (SESKOAD), 1987/1988Sekolah Staf dan Komando TNI Angkatan Darat (SESKOAD), 1987/1988

PELATIHANPELATIHAN

Combined Humanitarian Assistance Response Training, oleh Singapore Armed Forces (SAF), Singapura, 2000Combined Humanitarian Assistance Response Training, oleh Singapore Armed Forces (SAF), Singapura, 2000Health as a Bridge for Peace Workshop, oleh World Health Organization (WHO), Yogyakarta, 2000 Health as a Bridge for Peace Workshop, oleh World Health Organization (WHO), Yogyakarta, 2000

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PENGALAMAN JABATANPENGALAMAN JABATANKomandan Detasemen Kesehatan Pasukan Pengamanan Presiden (DanDenkes Komandan Detasemen Kesehatan Pasukan Pengamanan Presiden (DanDenkes Paspampres), 1987-1991Paspampres), 1987-1991Kepala Rumah Sakit “Muhammad Ridwan Meuraksa”, Jakarta, 1992Kepala Rumah Sakit “Muhammad Ridwan Meuraksa”, Jakarta, 1992Kepala Kesehatan Daerah Militer (Kakesdam) Jaya, Jakarta, 1993Kepala Kesehatan Daerah Militer (Kakesdam) Jaya, Jakarta, 1993Komandan Pusat Pendidikan Kesehatan TNI – AD,1995 – 1999Komandan Pusat Pendidikan Kesehatan TNI – AD,1995 – 1999Wakil Kepala Pusat Kesehatan TNI, 1999 – 2000Wakil Kepala Pusat Kesehatan TNI, 1999 – 2000Kepala RSPAD Gatot Soebroto, 2000 – 2002Kepala RSPAD Gatot Soebroto, 2000 – 2002Dekan Fakultas Kedokteran UPN, Jakarta, 2000 – 2002Dekan Fakultas Kedokteran UPN, Jakarta, 2000 – 2002Wakil Ketua Tim Dokter Kepresidenan RI, 2000 – 2002Wakil Ketua Tim Dokter Kepresidenan RI, 2000 – 2002Direktur Kesehatan TNI Angkatan Darat (Dirkesad), 2002-2004Direktur Kesehatan TNI Angkatan Darat (Dirkesad), 2002-2004 Wakil Ketua Tim Pemeriksaan kesehatan untuk calon Presiden dan calon Wakil Presiden RI Wakil Ketua Tim Pemeriksaan kesehatan untuk calon Presiden dan calon Wakil Presiden RI Th.2004Th.2004DOSEN Pasca Sarjana FKM UI, Kajian Administrasi Rumah Sakit (KARS)DOSEN Pasca Sarjana FKM UI, Kajian Administrasi Rumah Sakit (KARS)DIREKTUR UTAMA RUMAH SAKIT MMCDIREKTUR UTAMA RUMAH SAKIT MMC

ORGANISASIORGANISASIKetua Ikatan Rumah Sakit Jakarta Metropolitan (IRSJAM), 2000-2003Ketua Ikatan Rumah Sakit Jakarta Metropolitan (IRSJAM), 2000-2003Ketua Umum Perhimpunan Rumah Sakit Seluruh Indonesia ( PERSI), 2003-2009)Ketua Umum Perhimpunan Rumah Sakit Seluruh Indonesia ( PERSI), 2003-2009)Ketua Tim Kajian Globalisasi IDI Pusat.Ketua Tim Kajian Globalisasi IDI Pusat. Anggota Komnas FBPI. Anggota Komnas FBPI. Angggota TNP2K.Angggota TNP2K.Ketua Divisi Kemahkamahan Majelis Kehormatan Etik Kedokteran (MKEK) IDI Pusat Ketua Divisi Kemahkamahan Majelis Kehormatan Etik Kedokteran (MKEK) IDI Pusat Tim Konsultan Institut Manajemen Risiko Klinis ( IMRK )Tim Konsultan Institut Manajemen Risiko Klinis ( IMRK )Koordinator Bidang 1 : KAJIAN KESELAMATAN PASIEN, KKPRSKoordinator Bidang 1 : KAJIAN KESELAMATAN PASIEN, KKPRSInstruktur HOPE ( Hospital Preparedness for Emergencies and Disasters} Instruktur HOPE ( Hospital Preparedness for Emergencies and Disasters} PRESIDENT OF ASIAN HOSPITAL FEDERATION ( AHF ) 2009 – 2011PRESIDENT OF ASIAN HOSPITAL FEDERATION ( AHF ) 2009 – 2011

PATIENT SAFETY IS A KEY COMPONENT OF PATIENT SAFETY IS A KEY COMPONENT OF RISK MANAGEMENTRISK MANAGEMENT

Dr. ADIB A YAHYA, MARSPRESIDENT

ASIAN HOSPITAL FEDERATION( AHF )

WORKSHOP KESELAMATAN PASIEN DAN MANAJEMEN RISIKO KLINIS DI RUMAH SAKIT

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2. Why?

1. What?

3. How?

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What ?What ?

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DEFINISI RISIKODEFINISI RISIKO

RISIKO ADALAHRISIKO ADALAH : :

“ “ POTENSI TERJADINYA KERUGIAN POTENSI TERJADINYA KERUGIAN YANG DAPAT TIMBUL DARI PROSES YANG DAPAT TIMBUL DARI PROSES KEGIATAN SAAT KEGIATAN SAAT SEKARANGSEKARANG ATAU ATAU KEJADIAN KEJADIAN DIMASA DATANGDIMASA DATANG.”.”

ERM, Risk Management Handbook for Health Care OrganizationERM, Risk Management Handbook for Health Care Organization

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Risiko di Rumah SakitRisiko di Rumah Sakit

RISIKO KLINISRISIKO KLINIS : :SEMUA ISU YANG DAPAT BERDAMPAK SEMUA ISU YANG DAPAT BERDAMPAK

TERHADAP TERHADAP PENCAPAIAN PELAYANAN PASIENPENCAPAIAN PELAYANAN PASIEN YANG BERMUTU TINGGI,AMAN DAN EFEKTIF.YANG BERMUTU TINGGI,AMAN DAN EFEKTIF.

RISIKO NONKLINISRISIKO NONKLINIS/ Corporate Risk/ Corporate Risk : :

SEMUA ISSU YANG DAPAT BERDAMPAK SEMUA ISSU YANG DAPAT BERDAMPAK TERHADAP TERCAPAINYA TUGAS POKOKTERHADAP TERCAPAINYA TUGAS POKOK

DAN DAN KEWAJIBAN HUKUMKEWAJIBAN HUKUM DARI RUMAH SAKIT DARI RUMAH SAKIT SEBAGAI KORPORASISEBAGAI KORPORASI..

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KATEGORI RISIKO DI RUMAH SAKITKATEGORI RISIKO DI RUMAH SAKIT : : ( ( Categories of RiskCategories of Risk ) )

Patient care-related risksPatient care-related risks

Medical staff-related risksMedical staff-related risks

Employee-related risksEmployee-related risks

Property-related risksProperty-related risks

Financial risksFinancial risks

Other risksOther risks

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Risiko yang berhubungan dengan perawatan pasienRisiko yang berhubungan dengan perawatan pasien ((Patient care related risksPatient care related risks))

Direct association with Direct association with patient carepatient careConsequences of inappropriate or incorrectly performed Consequences of inappropriate or incorrectly performed medical medical treatmentstreatmentsConfidentiality Confidentiality and appropriate release of informationand appropriate release of informationProtection from Protection from abuseabuse, , neglectneglect and assault and assaultWas patient Was patient informed of risksinformed of risks??NondiscriminatoryNondiscriminatory treatment treatmentAppropriate Appropriate triage and transfertriage and transfer of patients from ER of patients from ERPatient participation in Patient participation in research studiesresearch studies and use of experimental and use of experimental drugs - was consent obtained?drugs - was consent obtained?Was Was patient dischargedpatient discharged appropriately? appropriately?

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Risiko yang berhubungan dengan tenaga medisRisiko yang berhubungan dengan tenaga medis

((Medical staff - related risksMedical staff - related risks))

- Credential Credential terhadap staf medis ?terhadap staf medis ?

- Tindakan medis sesuai Tindakan medis sesuai kompetensikompetensi dan dan prosedur bakuprosedur baku ? ?

- - Was patient Was patient properly managed properly managed ??

- Do we have adequately - Do we have adequately trained staff trained staff ??

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Risiko yang berhubungan dengan karyawanRisiko yang berhubungan dengan karyawan

((Employee related risksEmployee related risks))

- Risiko Risiko keselamatan dan kecelakaan kerjakeselamatan dan kecelakaan kerja

- Maintaining a - Maintaining a safe environmentsafe environment - - Employee Health PolicyEmployee Health Policy : :

. reducing risk of . reducing risk of occupational illness and injuryoccupational illness and injury

. providing for the . providing for the treatment and compensationtreatment and compensation of of workers for work-related illnesses or workers for work-related illnesses or

injuriesinjuries

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Risiko yang berhubungan dengan propertyRisiko yang berhubungan dengan property ((Property related risksProperty related risks))

Protect assets from losses due to Protect assets from losses due to firesfires, , floodsfloods, etc, etc

Paper and/or electronic recordsPaper and/or electronic records - patient, business - patient, business and financial - protected from damage or and financial - protected from damage or

destructiondestruction

Procedures for Procedures for handling cashhandling cash and safeguarding and safeguarding valuablesvaluables

Bonding and Bonding and insuranceinsurance to protect facility from to protect facility from losseslosses

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Risiko keuanganRisiko keuangan ((Financial risksFinancial risks))

– Bad DebtBad Debt

– Meningkatnya suku bungaMeningkatnya suku bunga

– Global Financial ” tsunami”Global Financial ” tsunami”

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Risiko lainRisiko lain

((Other risksOther risks))

- - Hazardous materialHazardous material management : management :

chemical, radioactive, infectious biological chemical, radioactive, infectious biological waste managementwaste management

- - Legal & regulatoryLegal & regulatory risks risks

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WHY ?WHY ?

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HOSPITALHOSPITAL

System made up of thousands of System made up of thousands of

inter-linked processesinter-linked processes……………..……………..

things can go wrongthings can go wrong

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Errors are inevitable

………….but most are preventable

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HOW ?HOW ?

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DIDALAM SISTEM KITA YANG SANGAT KOMPEKS INI …..BAGAIMANA KITA AKAN MENDARAT DENGAN SELAMAT ?

BAHAYA / HAZARD / RISIKO YANG MANA YANG HARUS KITA TANGANI TERLEBIH DAHULU ?

2020

MANJEMEN RISIKO

. . . ADALAH PENDEKATAN PROAKTIF UNTUK MENGIDENTIFIKASI,MENILAI DAN MENYUSUN PRIORITAS RISIKO,

DENGAN TUJUAN UNTUK MENGHILANGKAN ATAU

MEMINIMALKAN DAMPAKNYA.

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RISK MANAGEMENT PROCESSRISK MANAGEMENT PROCESS

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PROSES MANAJEMEN RISIKOPROSES MANAJEMEN RISIKO

KO

MU

NIK

AS

I D

AN

KO

NS

UL

TA

SI

MO

NIT

OR

DA

N R

EV

IEW

TEGAKKAN KONTEKS

IDENTIFIKASI RISIKO

ANALISA RISIKO

EVALUASI RISIKO

KELOLA RISIKO

ASESMEN RISIKOASESMEN RISIKO

RISK REGISTERRISK REGISTER

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RISK MANAGEMENT TECHNIQUES/TREATMENTSRISK MANAGEMENT TECHNIQUES/TREATMENTS

RISK CONTROLRISK CONTROL : :

- - EXPOSURE AVOIDANCEEXPOSURE AVOIDANCE- LOSS PREVENTION- LOSS PREVENTION- LOSS REDUCTION- LOSS REDUCTION

- SEGREGATION (SEPARATION OR DUPLICATION)- SEGREGATION (SEPARATION OR DUPLICATION)- CONTRACTUAL TRANSFER FOR RISK CONTROL- CONTRACTUAL TRANSFER FOR RISK CONTROL

RISK FINANCINGRISK FINANCING : :

- - RISK RETENTIONRISK RETENTION- RISK TRANSFER- RISK TRANSFER

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IMPLEMENTASI IMPLEMENTASI MANAJEMEN RISIKO KLINIK MANAJEMEN RISIKO KLINIK

DI RUMAH SAKITDI RUMAH SAKIT

PRIMUM, NON NOCEREPRIMUM, NON NOCEREFIRST, DO NO HARMFIRST, DO NO HARM

HIPPOCRATES’S TENET HIPPOCRATES’S TENET (460-335 BC)(460-335 BC)

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Risiko Risiko SELALU MELEKATSELALU MELEKAT dengan dengan proses pengobatan kepada proses pengobatan kepada

pasien itu sendiripasien itu sendiri

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RISIKO MENYATU DENGAN SEMUA ASPEK PELAYANAN KESEHATAN,TERMASUK :

• pengobatan dan perawatan kepada pasien;

• menentukan prioritas pelayanan ;

• pengembangan proyek dan pelayanan ;

• pembelian obat dan produk kesehatan lain;

• instruksi dan follow up kepada pasien.

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CRITICAL POINTS IN CLINICAL RISK MANAGEMENTCRITICAL POINTS IN CLINICAL RISK MANAGEMENT

PROVIDING CARE IN THE PROVIDING CARE IN THE EMERGENCY ROOMEMERGENCY ROOMMAKING A MAKING A DIAGNOSISDIAGNOSIS

ORDERING ORDERING INVESTIGATIONS AND INTERPRETINGINVESTIGATIONS AND INTERPRETING THE RESULTSTHE RESULTS

UNDERTAKING UNDERTAKING INVASIVE PROCEDURESINVASIVE PROCEDURESDRUG DRUG TREATMENTTREATMENT

WARDWARD MANAGEMENT MANAGEMENT

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RISK MANAGEMENT IN RISK MANAGEMENT IN ERER

POTENTIAL ERRORSPOTENTIAL ERRORS

Assessment of emergencies Assessment of emergencies by by insufficiently experienced insufficiently experienced junior staffjunior staff

Inadequate use of Inadequate use of specialist specialist opinionopinion

Inadequate reading of simple Inadequate reading of simple radiographsradiographs

Poor management of Poor management of standard standard situationsituation

Inadequate Inadequate assessment before assessment before dischargedischarge

REDUCING/MINIMISING RISKSREDUCING/MINIMISING RISKS

Experienced clinicians available Experienced clinicians available full-timefull-time

Involvement of specialist in the Involvement of specialist in the training of stafftraining of staff

Training of staffTraining of staff

““on call” radiologiston call” radiologist

Use protocols with sensitivityUse protocols with sensitivity

Senior staff to take responsibility Senior staff to take responsibility for dischargesfor discharges

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REDUCING REDUCING DIAGNOSTIC DIAGNOSTIC ERRORERROR

POTENTIAL ERRORSPOTENTIAL ERRORS

Failure to take a well-focused Failure to take a well-focused case historycase history

Failure to assess the Failure to assess the evidence & evidence & make a DDmake a DD

Inappropriate Inappropriate use of testsuse of tests

Leaving the problem Leaving the problem unexplainedunexplained

REDUCING/MINIMISING RISKSREDUCING/MINIMISING RISKS

Concentrate on key elementsConcentrate on key elements

Better trainingBetter training

Write down conclusions before Write down conclusions before making a planmaking a plan

Define spesific quuestios to be Define spesific quuestios to be answered by chosen testsanswered by chosen tests

Get a second opinionGet a second opinion

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REDUCING THE RISKS OF REDUCING THE RISKS OF INVESTIGATIONINVESTIGATION

POTENTIAL ERRORSPOTENTIAL ERRORS

Clinician Clinician misreadsmisreads visual visual evidence e.g. x ray; ECGevidence e.g. x ray; ECG

Clinician not aware of Clinician not aware of lab resultslab results

Clinician not aware of Clinician not aware of ward ward observationobservation

Clinician fails to Clinician fails to understand test understand test resultresult

Inappropriate Inappropriate use of testsuse of tests

REDUCING/MINIMISING RISKSREDUCING/MINIMISING RISKS

Fully trained staff to interpret and Fully trained staff to interpret and report on testsreport on tests

Clinically important results to be Clinically important results to be relayed to clinician urgentlyrelayed to clinician urgently

Ward tests to be supervised and Ward tests to be supervised and results discussed with cliniciansresults discussed with clinicians

Aware of the limits of their Aware of the limits of their competencecompetence

Senior staff to check repeatedlySenior staff to check repeatedly

Careful supervisionCareful supervision

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Reducing the risks of Reducing the risks of invasive proceduresinvasive procedures

Consider The Consider The risk : benefit ratiorisk : benefit ratio

Discuss theDiscuss the procedure with the patient procedure with the patient

Carrying out the procedure including coping with Carrying out the procedure including coping with potential difficultiespotential difficulties

Ensure that the equipment is in good working order Ensure that the equipment is in good working order and that and that back up equipmentback up equipment is available is available

If the procedure is not going well obtain If the procedure is not going well obtain help / be help / be prepared to give upprepared to give up

Ensure that the operator has Ensure that the operator has sufficient skillsufficient skill

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Reducing the risks of Reducing the risks of invasive proceduresinvasive procedures

Consider The Consider The risk : benefit ratiorisk : benefit ratio

Discuss theDiscuss the procedure with the patient procedure with the patient

Carrying out the procedure including coping with Carrying out the procedure including coping with potential difficultiespotential difficulties

Ensure that the equipment is in good working order Ensure that the equipment is in good working order and that and that back up equipmentback up equipment is available is available

If the procedure is not going well obtain If the procedure is not going well obtain help / be help / be prepared to give upprepared to give up

Ensure that the operator has Ensure that the operator has sufficient skillsufficient skill

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COMMON SPECIFIC FACTORS ASSOCIATED WITH COMMON SPECIFIC FACTORS ASSOCIATED WITH DRUG DRUG ADVERSE EVENTSADVERSE EVENTS

FAILURE TO TAKE ACCOUNT OF DECLINING FAILURE TO TAKE ACCOUNT OF DECLINING RENAL / HEPATIC FUNCTIONRENAL / HEPATIC FUNCTION

FAILURE TO CHECK FOR POSSIBLE FAILURE TO CHECK FOR POSSIBLE ALLERGIC ALLERGIC RESPONSESRESPONSES

USING THE USING THE WRONG DRUG NAMEWRONG DRUG NAME OR MEANS OF OR MEANS OF ADMINISTRATIONADMINISTRATION

MISCALCULATION OF MISCALCULATION OF DOSAGEDOSAGE

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REDUCING THE RISKS OF ONGOING REDUCING THE RISKS OF ONGOING WARD CAREWARD CARE

POTENTIAL ERRORSPOTENTIAL ERRORS

Failure to Failure to monitormonitor clinical clinical progressprogress

Failure to recognise that a Failure to recognise that a patient is patient is not making not making satisfactory progresssatisfactory progress

Failure to provide Failure to provide appropriate appropriate treatmenttreatment

ShiftShift working working

REDUCING.MINIMISING RISKSREDUCING.MINIMISING RISKS

Joint education regarding Joint education regarding appropriate monitoringappropriate monitoring

Regular supervisionRegular supervision

Use spesialist staff – clinician Use spesialist staff – clinician from appropriate unit, nurse from appropriate unit, nurse spesialist, physiotherapistspesialist, physiotherapist

Briefing & de-briefingBriefing & de-briefingSBARSBAR

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PATIENT SAFETY,QUALITY OF CAREPATIENT SAFETY,QUALITY OF CARE

AND RISK MANAGEMENTAND RISK MANAGEMENT

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The basic principles for safety The basic principles for safety and quality of careand quality of care

The basic principles for patient safety are The basic principles for patient safety are the the principles for quality of careprinciples for quality of care: :

- to - to do the right thingdo the right thing

for the for the right patientright patient

using the using the right methodright method and and

at the at the right timeright time, and , and

- to - to communicate wellcommunicate well with the with the patient patient and the rest of the and the rest of the clinical teamclinical team

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““It’s easy gettin’ good players.It’s easy gettin’ good players.The hard part is gettin’ them to play The hard part is gettin’ them to play

with each other”with each other”

(Casey Stengel)

(Casey

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Communicating Team ???Communicating Team ???

4040

Quality in HealthcareQuality in Healthcare

……. begins with . begins with ensuring patient safetyensuring patient safety

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Key reasonsKey reasons

Patients are Patients are more at riskmore at risk than non-patients than non-patients

Medical interventions are, by their nature, Medical interventions are, by their nature, high-risk procedures - high-risk procedures - small error small error

marginsmargins

Medicine remains an Medicine remains an inexactinexact, hands-on , hands-on endeavourendeavour

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Patient safety in contextPatient safety in context

Patient safetyPatient safety is an important component of is an important component of

risk managementrisk management, , clinical governanceclinical governance, and , and quality improvementquality improvement. .

4343Australian Patient Safety Foundation

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I. Risk management is not primarily about avoiding or mitigating claims; rather, it is a tool for

improving the quality of care.

II. Incident reporting is only one aspect of the identification of risk. 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

clinical governance and patient safety.

CONCLUSIONSCONCLUSIONS

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FINAL WORDFINAL WORD

……Safe care is not an option. It is the right of every patient

who entrusts their care to our Healthcare systems…Sir Liam Donaldson,

Chair, WHO World Alliance for Patient Safety, Forward Programme, 2006–2007

4646TERIMAKASIHTERIMAKASIH