AA RAKA KARSANA

CREDENTIALING, PRIVILEGING
DAN PATIENT SAFETY
HOW SAFE IS HEALTHCARE
Contamination Where things have gone wrong -
Johannesburg

Death of Babies due to Serratia

contamination
1990: 15 babies died at two Johannesburg
hospitals after being given contaminated
TPN
The bags were made in an isolator by a
commercial company (Sabax)
Components sterilised with gas/vapour
Good procedures used

Operator Ignorance
Poor procedures
EKSTRAVASASI AKIBAT
PEMBERIAN OBAT SITOTOKSIK
OLEH PETUGAS YG TDK MEMILIKI
PRIVILEGE
MENGAPA TERJADI INSIDEN?

HUMAN
ERROR

Design
work/system

AKREDITASI
(JCIA/KARS)
STANDAR DALAM AKREDITASI

Inputs: Resource (SDM)

Processes: Activities
Outcomes: Results
BAGAIMANA RS MENJAGA STANDARD
INPUT KHUSUSNYA SDM MENURUT
AKREDITASI?