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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............................................. .............................. dan hasilnya: ............................................................................................................... .................... Insiden menyangkut pasien: o Pasien rawat inap o Pasien rawat jalan o Pasien UGD o Lain- lain . Tindakan dilakukan oleh: .............................................................................................................................. 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 ....................................................................................... ..................................................................... ...................................................................... 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........ ................................................... ............................................. Insiden terjadi pada: o Pasien o Lain- lain ......................

................................................ terdiri dari ............................................................................................. o Dokter o Perawat o Bidan o Petugas lainnya ................................................................................................................................. ............................................................................................... o Tidak Pembuat Laporan Penerima Laporan (.......................... 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:.... .................................................. .................................................. ..... .............................................................................................................................................................................................) Tanggal Terima: Tanggal Terima: ___________________ ___________________ ......................... o Tim......................................................................) (...............................................................................................