Raising the culture of

Patient Safety and Total Care

KATI 2021

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 1 attitude = opinion…
everyone’s attitude = culture

Merubah budaya (culture)

= merubah attitude dari banyak manusia

Semoga ratusan PPDS ini

dapat bersama mendukung
Patient Safety dan Total Care

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 sehat

pembedahan + anestesia

sakit it

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4
 Pasien datang
sebagai insan yang .......

1. butuh pertolongan medis / pengobatan

2. berharap sembuh dan terbebas dari
sakitnya
3. perlu dilindungi terhadap risiko penyulit
dari proses pengobatannya

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• Doctors are responsible ethically, for
their patient’s safety.

• It is the duty of the surgeon to decide,

when to operate or not to operate

• Patient safety is a set of measures to

safeguard patients from possible harms
during medical care and treatment

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Tetapi, mengapa jadi begini .....?

Medical Error Is Third Leading

Cause of Death in US - 2013

Medscape Medical News

Marcia Frellick
May 03, 2016

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Good doctors keep the ethics…

Do not compromise!
If you have to compromise anyway,
never compromise safety

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Health care is often delivered in a dynamic
environment with complex interactions
among patients, medical staff, infrastructure,
equipment, and policies and procedures

(Institute of Medicine, 1999; Nolan, 2000).

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RUMAH SAKIT

pembedahan + anestesia

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Examples of adverse drug events include wrong
dose, wrong choice, wrong drug, wrong technique,
equipment failure, etc.

The majority of adverse drug events were of

minor consequence (35.4%), no clinical importance
(57.5%), major morbidity in only 1.4%, and death in
less than 0.4% (Orser et al., 2000).

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 Are these minor consequences?
• Antibiotics diluted in KCl
• Antibiotics diluted in suxamethonium
• LASA:
– Oradexon mistaken with Pavulon
– Valium mistaken with Alloferin
– Ephedrine mistaken with epinephrine
• Morphin 1mg iv mistaken with 10 mg iv
• KCl iv drip mistaken with iv bolus

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 mistake is mistake

• If you do not repair the system .....

• It will run carrying the latent error ....
• Whenever it meets an active error,
bad things happen .....

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what adverse effects may result ?

• Dis-satisfaction
• Discomfort
• Disability
• Disease
• Death
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 Laki, 60 th dengan hernia sebesar kelapa,
datang berjalan sendiri.
Dioperasi herniotomi, usus direposisi.
• Sampai hari ke 3 tidak flattus, perut besar 
“ah.. tidak apa-apa, sabar saja, masih ileus
paralitik, periksa elektrolit, mungkin hipokalemia !”
• Hari ke 4 shock, Hb 12 jadi 6, perut besar 
“ah.. hipovolemia, beri cairan dan transfusi.
Mungkin sepsis, ganti antibiotika”

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 Mana faktor yang bisa menyelamatkan
pasien ini

• Sampai hari ke 3
tidak flattus, perut
besar  1. Good Clinical Governance ?
• Hari ke 4 shock, Hb 2. Clinical Pathway ?
12 jadi 6, perut 3. Protap ?
besar  Mungkin 4. Guidelines ?
sepsis, ganti
5.Kerja yang baik ?
antibiotika.

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Pasien di operasi ulang
Abdomen berisi cairan hemoragis 2 liter
Usus nekrosis 2 meter
Proses inflamasi seluruh peritoneum
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Mortuis vivos docent

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 Institute of Medicine Survey
Building a Safer Health System (2000)

• Medical errors are responsible for injury in 1

out of every 25 hospital patients
• An estimated 48,000-98,000 patients die
from medical errors each year.
• Higher than annual mortality from motor vehicle
accidents (43,458), breast cancer (42,297), or AIDS
(16,516)

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 Bagaimana sih the real patient safety
measures itu ?
• Anda menerima tilpun dari RS. “Dok, dari RS X kamar
234, ada konsul dari Dr A dengan tumor colon.”
• Anda menulis di agenda segera setelah tilpon ditutup
• Sore Anda ke RS A, datang ke nurse station dekat
kamar 234 dan mengidentifikasikan diri Anda
• “Zus, saya Dr Willy yang tadi dikonsuli Dr A pasien
dengan tumor colon”
• “Bagaimana cerita pasien ini. Pak .... siapa namanya ?”
• “Pak Anwar, ini tadi baru CT scan abdomen, dok.”
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• Perawat mengantar Anda ke kamar pasien.
• Sapalah dia, “selamat sore, dengan pak Anwar?
Saya Dokter Willy, dokter bedah. Tadi Dokter A
konsul minta pertimbangan saya tentang
bapak.”
• Dst, dst ....

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• Sampai sejauh ini, Anda pasti telah lakukan ini
meski perlu tambahan waktu. Tetapi sapaan ini
juga perlu diulang waktu Anda masuk ruang
persiapan waktu akan operasi. Pasien akan
merasa nyaman bahwa betul dokter Willy telah
datang untuk operasi tersebut.
• Dan Anda sudah aman dari risiko melakukan
bedah pada pasien yang salah dan atau tempat
operasi yang salah.

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 WSS / WPS
• Wrong-site surgery was accompanied by a 2.7%
mortality, a 41.5% permanent injury rate, and a
mean liability payment of $127,159. Wrong-
patient surgery had a 7.7% mortality, a 26.9%
permanent injury rate, and a mean liability
payment of $109,648. There are system
processes that can reduce this unacceptable
human cost and financial burden.
• Search - wrong site surgery statistics (bing.com)

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 Kasus postop - pain
• Pasien 30 th, operasi HNP.
• Post op diberi Ketorolac 3x80 mg iv 2 hari.
• Lalu dilanjutkan 3 x 80 mg tablet 2 hari
• Pasien pindah ke ruangan. Ternyata obat
dilanjutkan 10 hari untuk memudahkan
fisioterapi.
• Pasien melena, shock, Hb tinggal 5 gm/dl
Kembali masuk ICU, mendapat transfusi 20 bag,
Beruntung selamat.

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So ….
• Ada Duty owed: pasien perlu berobat
• Ada Breach of duty: pengobatan tidak
sesuai standar / clinical pathway
• Ada Injury: terjadi perforasi usus
• Ada Proximity / cause-effect relationship:
batasan dosis dan lama pemakaian
ketorolac tidak diikuti
+
Malpraktek
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 What happen in U.S. Healthcare system ?

• 7% of patients suffer a medication error 2

• Every patient in ICU suffers an adverse
event 3,4

2. Bates DW, Cullen DJ, Laird N, et al., JAMA, 1995

3. Donchin Y, Gopher D, Olin M, et al., Crit Care Med, 1995.
4. Andrews L, Stocking C, Krizek T, et al., Lancet, 1997.

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 Patient Safety encompasses the processes
1. that protect patients from injury caused by
medical mismanagement.

Ensuring patient safety requires operational

2. systems and processes that will maximize the
likelihood of preventing adverse medical events
(Institute of Medicine, 1999)

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Patient safety start with
Ethical Consideration
Cost
Risk
Injury

Benefit
Relief
Comfort

"For a treatment option to be morally

justified, there has to be a greater benefit
than burden"

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 Principles of Safe Design
1. Standardize
– Eliminate steps if possible
2. Create independent checks
3. Learn when things go wrong
– What happened
– Why
– What did you do to reduce risk
– How do you know it worked

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Create independent checks

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 Learn when things go wrong
• Pukul 23 pasien bed 3 tiba2 aritmia, SVT.
• Dokter jaga berteriak, “ambil DC shock”
• Cardioversion 100 Joules berhasil.
• Selesai. Pasien sudah selamat .
• Jika kita puas disini, maka itu belum mendukung
Patient Safety. Lho ?
• Anda belum belajar ketika pasien mengalami
aritmia. Mengapa dia aritmia?
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 Aritmia SVT

Sebab intra-kardial Sebab ekstra-kardial

• Miokard irritable • Hipoksia
• Kelainan elektrolit • Saturasi O2 turun
• Dst, dst • Hiperkarbia
• Nyeri berlebihan

Rekaman Saturasi oksigen pada jam 22.15 sampai

23.00 imenunjukkan 85%. Pemeriksaan lebih teliti
menemukan sambungan tubing O2 ke masker pasien
terlepas.
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 can we prevent and avoid these events?

• Medication • wrong drug, dose, route

• Airway • acc extubation, airway
obstruction, cuff leak
• Lines, drains, cath • dislodgement,
disconnection
• Equipment failures • power supply, oxygen
supply, ventilator,
infusion pump
• Alarms • inappropriate turn off

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35
 1--1000 mobil sama
Bahan
baku
Bahan
baku Proses produksi

Bahan
terstandar baku

kondisi pasien
ber-variasi
Apa bisa hidup
Proses di ICU semua??

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 System Failure Leading to Error
Catheter pulled with
Patient sitting Communication between
resident and nurse

Inadequate training
and supervision

Patient suffers Lack of protocol

For catheter removal

8. Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004.

9. Reason J, Hobbs A., 2000.

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 KCl iv bolus accident

Head nurse order student nurse

to administer
No drug alert
No SOP
No one to ask

Doctor ordered KCl

lab report: K = 2.0

Child suffered Student did not know

rules of KCl administration
cardiac arrest

8. Pronovost PJ, Wu Aw, Sexton, JB et al., Ann Int Med, 2004.

9. Reason J, Hobbs A., 2000.

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AHRQ Survey : Evidence of Quality
Problems: one in six hysterectomies was
inappropriate.

A national study over a 10-year period

(1983-93) found:
- deaths due to medication errors rose
> two-fold, 7,391 deaths in 1993.

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 Surgical adverse events

• Occurred in 1 of 50 admissions in
Colorado and Utah hospitals (1992),
• Accounted for 2/3 of all adverse events
and 1 of 8 hospital deaths

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• Effective communication amongst caregivers is
essential for a functioning team
• The Joint Commission reports that ineffective
communication is the most common cause
for a sentinel event
• Observations of ICU teams have shown errors in
the ICU to be concentrated after communication
events (shift change, handoffs, ect)
• 30% of errors are associated with
communication between nurses and
physicians

Reader, CCM 2009 Vol 37 No 5;

Donchin CCM 1995 Vol 23 42
Seorang anak yang sering
tonsilitis akut dianjurkan
Operasi Tonsilektomi

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 15 items bisa “error”

1. Periksa oleh Dr THT 9. Suntik obat anestesia

2. Periksa oleh Dr Anest 10. Obat pelumpuh otot
3. Ambil darah, periksa lab 11. Intubasi, nafas buatan
dengan oksigen dan N2O
4. Masuk RS, nama di
status 12. Operasi, perdarahan
13. Operasi selesai belum
5. Suntik premedikasi
sadar kembali
6. Tidur, dibawa ke OK 14. Muntah, edema larynx,
7. Pasang infus spasme larynx, cyanosis
8. Suntik antibiotika 15. Nyeri, alergi analgesic

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 Untuk menjamin Patient safety

• Semua 15 items perjalanan klinik tadi

harus betul
• Reaksi tubuh pasien terhadap obat yang
sudah betul juga harus betul
(tidak boleh alergi)

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Murphy’s law:

If anything can go wrong, it will go wrong

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RS ini bersertifikat ISO, bertaraf “Internasional”
Apakah sertifikat ISO menjamin Patient Safety ?
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 Risk Management

Clinical Governance
Safety
Patient

Quality Improvement
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 Risk Management

2
3 Risk Analysis
Risk Elimination
or Minimization
1
Risk Identification

4 Evaluation 49
 Kendali risiko dari Fish-bone analysis
untuk mencapai Good Outcome

Method Machine Man

Good
Ill patient hospitalization
Outcome

Money Materials Environment

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 Man Money

Machine Method

Materials Environment

Asuransi minta biaya murah

Rumah Sakit minta ada profit
Dokter tidak mau jadi sapi perahan

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Clinical Governance

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 Effective Clinical Governance ensures

• continuous improvement of patient care

• a patient centred approach that includes
– treating patients courteously,
– involving them in decisions about their care and keeping
them informed
• a commitment to quality, which ensures that
– health professionals are up to date in their practices
– properly supervised where necessary
• a reduction of the risk from clinical errors and
adverse events
• a commitment to learn from mistakes and share that
learning with others

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 Tanki gas di RS** th 2002
6 bulan setelah kejadian
Bengkulu

Peristiwa Bengkulu
2 dokter dipenjara

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Safety is accident prevention

• Be prepared
• Minimize variables
• Minimize alternatives
• Use only approaches with
widest margin of safety

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 Upaya Patient’s Safety

Homogenisasi Homogenisasi Proses

INPUT = Clinical Pathway

INPUT PROCESS OUTPUT

INPUT

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 Mortality associated w/ anesthesia

• MHA National Aggregate Data :

– Class I 1 : 10,000
– Class II 3 : 10,000
230 x lipat
– Class III 28 : 10,000
– Class IV 230 : 10,000

(Maryland Hospital Assoc.1999)

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• Adanya co-morbids menyebabkan variasi
input. Jika co-morbid bisa dihilangkan atau
dikendalikan, risiko berkurang dan survival
meningkat.
• Jika dengan usaha maksimal variasi input
tidak dapat diminimalkan, maka prosedur
bedah terpaksa berubah.
Contoh, Damage Control Surgery

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Stardardisasi Proses = Clinical Pathway

Px diare Beri infus Periksa darah Sembuh, pulang

Infus RL Kadar Hb, leuko

20 cc/kg Biakan kuman
dalam 1jam Fungsi ginjal
lanjut kan dst Kadar Na, K
Ukur tek darah
tiap 15 menit dst

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Korban luka bakar 90% permukaan tubuh
Cedera thermal paru dan jalan nafas 61
 Luka bakar 90% permukaan tubuh
Cedera thermal paru dan jalan nafas

• Clinical pathway luka bakar kulit memberi

cairan 15 liter, jika kurang, pasien shock
• Clinical pathway cedera thermal paru
melarang cairan banyak karena memicu
edema paru

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 Px diare Beri infus Periksa darah Sembuh, pulang

Children’s Hospital Central California

Gastroenteritis pathway : 10 lembar kwarto, 230 KB

Include in pathway :
-Patients with simple gastroenteritis
-Patients with stable vital signs
-Patients with estimated dehydration less than 10% ….(4 items)

Exclude from the pathway :

•Patients less than 1 month old
•Patients with estimated dehydration more than 10%
•Patients with significant chronic co-morbids
•Patients with diarrhea more than 5 days ….. (6 items)
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 MEDICAL ETHICS

GOOD TRAINING
& COMPETENCE

GOOD GOOD GOOD

NURSE HOSPITAL DOCTOR

good good
care treatment

+
PATIENT SAFETY GOOD
RESULT

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 Patient safety is a set of measures to
safeguard patients from possible harms
during medical care and treatment

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That water will not cure her anyway,
but that soothing touch will bring both
women to heaven

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 Take home message
1. Be empathetic → empati pada derita px
2. Be considerate → pertimbangkan semua
aspek, timbanglah antara hasil dan risiko
3. Be moderate → tidak berlebih-lebihan
baik dalam janji maupun tindakan
4. Be honest → jujurlah bahwa kalau kita
berhasil itu hanya atas ridha Allah swt

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Wassalamualaikum
wr wb

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 Total care
• Meluaskan aplikasi llmu kedokteran dengan pendekatan
individual menyeluruh
• Seorang pasien 70 th dengan hernia incarcerata ketika
mengeluh ke RS harus diperiksa head to toe seperti
Secondary Survey pasien trauma.
• Ketika ditemukan Blood Sugar 300 dan HbA1cnya 7.5
maka konsul ke SpPD. Hiperglisemia meningkatkan
risiko sepsis. Maka dilakukan regulasi insulin sampai BS
< 200
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 Total care
• CT scan menunjukkan brain atrofi maka konsul ke
Neurologi karena fluktuasi tensi selama anestesi
akan mengganggu perfusi cortex dengan risiko
stroke atau Post Operative Cognitive Disorder
• Pasien ini usia 70 th, maka ada risiko 60-70%
menderita PJK. Perlu diperiksa echo-cardiografi.
• Ternyata ada old infarction anteroseptal. EF hanya
30%
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 10 pertanyaan awal
(searah dengan risk management)
1. Triage
2. Diagnosis
3. Kasus bedah?
4. Masalah yang dapat timbul?
5. Jenis tindakan / tehnik operasi
6. Timing operasi?
7. Problim pra-bedah
8. Problim intra-bedah
9. Problim pasca-bedah
10. Follow-up
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• Cara ini diharapkan dapat memetakan segala
permasalahan dan kemungkinan yang bisa
terjadi hingga setiap penyimpangan dapat
segera di deteksi dan dikoreksi bahkan
dieliminasi
• Contoh, ketika hari ke 2 pasien hernia ini masih
belum flattus, maka dipertimbangkan untuk USG
abdomen atau imaging yang lain bukan hanya
memberi tablet KCl atau vitamin B

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 Contoh # 8. Problim intra-bedah

• Apa anestesianya: mungkin banyak yang usul

anestesia spinal (SAB). SAB bukan pilihan yang
aman karena EF hanya 30%.
• Begitu blok masuk, pasien vasodilatasi, tensi
drop, perfusi koroner turun, cardiac arrest
• Lebih lagi pasien ini ada diabetes, dimana
umumnya aktifitas syaraf simpatis menurun,.
• Apapun anestesianya siapkan DC shock.

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 Contoh # 10. Follow-up
• Hari ketiga pasien sudah makan, normal.
• Mulai terapi aspirin-clopidogrel karena ada ST
elevasi.
• Pasien disiapkan untuk operasi prostatnya bulan
mendatang karena menjadi penyebab hernia.

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