PEMERINTAH KABUPATEN MALANG

DINAS KESEHATAN
UPTD PUSKESMAS TUREN
Jl. Panglima Sudirman 210 Turen Telp. 0341-
824214
Email: puskturen@yahoo.com
MALANG

FORMULIR PELAPORAN INSIDEN KESELAMATAN PASIEN

1. Data Korban:
Nama :
Umur :
Jenis Kelamin :

2. Rincian Kejadian
Tanggal :
Waktu :

Insiden :

Kronologi : .................................................................................................
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Jenis Insiden :
o Kejadian Nyaris Cedera / KNC
o Kejadian Tidak Cedera / KTC
o Kejadian Tidak Diharapkan / KTD

Orang pertama yang melaporkan:

o Karyawan : dokter / Perawat / Bidan / Petugas Lainnya
o Pasien
o Keluarga pasien
o Pengunjung
o Lain-
lain ..................................................................................................
.......
Insiden terjadi pada:
o Pasien
o Lain-
lain ..................................................................................................
.......
Insiden menyangkut pasien:
o Pasien rawat inap
o Pasien rawat jalan
o Pasien UGD
o Lain-
lain ..................................................................................................
.......

Tempat kejadian:

Unit terkait yang menyebabkan insiden:

Akibat insiden terhadap pasien:

o Kematian
o Cedera berat
o Cedera sedang
o Cedera ringan
o Tidak ada cedera

Tindakan segera yang dilakukan setelah kejadian, dan

hasilnya: ......................................................................................................
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Tindakan dilakukan oleh:

 o Tim, terdiri dari ...............................................................................
o Dokter
o Perawat
o Bidan
o Petugas lainnya ..............................................................................
Apakah kejadian yang sama pernah terjadi di unit kerja yang lain?
o Ya
Waktu kejadian:
Langkah atau tindakan yang telah diambil pada unit kerja
tersebut untuk mencegah berulangnya kejadian yang
sama:...............................................................................................
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o Tidak

Pembuat Laporan Penerima Laporan

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Tanggal Terima: Tanggal Terima:

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