NOVEMBER

NOVEMBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL

Jumlah pasien yang di

operasi dalam 1 bulan 4 10 13 6 13 4 2 10 8 11 6 4 3 3 8 4 10 6 11 5 2 9 5 9 8 9 1 0 6 6 196

SPM NOVEMBER
1. Kejadian Kematian di Meja Operasi
1 1 1
NOVEMBER 1 2 3 4 5 6 7 8 9 10 12 14 15 16 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL
1 3 7
Numerator 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0%
Denominator 4 10 13 6 13 4 2 10 8 11 6 4 3 3 8 4 10 6 11 5 2 9 5 9 8 9 1 0 6 6 196

2. Komplikasi Anesthesi Karena Over Dosis, Reaksi Anesthesi, Dan Salah Penempatan Endotracheal Tube
1 1 2
NOVEMBER 1 2 3 4 5 6 7 8 9 11 12 13 14 15 17 18 19 20 21 22 23 24 25 26 27 29 30 TOTAL
0 6 8
Numerator 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1
0,4%
Denominator 4 10 13 6 13 4 2 10 8 11 6 4 3 3 8 4 10 6 11 5 2 9 5 9 8 9 1 0 6 6 196

3. Tidak Adanya Kejadian Operasi Salah Orang

1
NOVEMBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL
7
Numerator 4 10 13 6 13 4 2 10 8 11 6 4 3 3 8 4 10 6 11 5 2 9 5 9 8 9 1 0 6 6 196
100%
Denominator 4 10 13 6 13 4 2 10 8 11 6 4 3 3 8 4 10 6 11 5 2 9 5 9 8 9 1 0 6 6 196

4. Tidak Adanya Kejadian Operasi Salah Sisi

1 1
NOVEMBER 1 2 3 4 5 6 7 8 9 10 11 12 14 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL
3 5
Numerator 4 10 13 6 13 4 2 10 8 11 6 4 3 3 8 4 10 6 11 5 2 9 5 9 8 9 1 0 6 6 196
100%
Denominator 4 10 13 6 13 4 2 10 8 11 6 4 3 3 8 4 10 6 11 5 2 9 5 9 8 9 1 0 6 6 196

5. Tidak Adanya Kejadian Salah Tindakan Pada Operasi

1
NOVEMBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL
7
Numerator 4 10 13 6 13 4 2 10 8 11 6 4 3 3 8 4 10 6 11 5 2 9 5 9 8 9 1 0 6 6 196
100%
Denominator 4 10 13 6 13 4 2 10 8 11 6 4 3 3 8 4 10 6 11 5 2 9 5 9 8 9 1 0 6 6 196

6. Tidak Adanya Kejadian Tertinggalnya Benda Asing Pada Tubuh Pasien Setelah Operasi
NOVEMBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 1 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL
 7
Numerator 4 10 13 6 13 4 2 10 8 11 6 4 3 3 8 4 10 6 11 5 2 9 5 9 8 9 1 0 6 6 196
100%
Denominator 4 10 13 6 13 4 2 10 8 11 6 4 3 3 8 4 10 6 11 5 2 9 5 9 8 9 1 0 6 6 196

7. Waktu Tunggu Operasi Elektif

1 1 1
NOVEMBER 1 2 3 4 5 6 7 8 9 10 12 14 15 16 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL
1 3 7
Numerator 4 5 13 6 10 0 0 5 7 8 5 4 0 0 8 3 8 5 8 0 0 6 4 9 7 7 0 0 2 5 139
1
Denominator 4 5 13 6 10 0 0 5 7 8 5 4 0 0 8 3 8 5 8 0 0 6 4 9 7 7 0 0 2 5 139

INDIKATOR MUTU RS NOVEMBER

1. Pasien Pasca Pembiusan di Transfer dari Recovery Room IBS ke Ruang Rawat Inap Sesuai dengan ALDRETTE SCORE
1 1
NOVEMBER 1 2 3 4 5 6 7 8 9 10 12 13 14 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL
1 5
Numerator 8 5 2 4 9 6 2 6 2 0 3 9 11 10 3 1 0 3 1 5 0 0 4 9 4 13 4 2 4 5 135
100%
Denominator 8 5 2 4 9 6 2 6 2 0 3 9 11 10 3 1 0 3 1 5 0 0 4 9 4 13 4 2 4 5 135

2. Angka Penundaan Operasi

NOVEMBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL
Numerator 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0%
Denominator 4 10 13 6 13 4 2 10 8 11 6 4 3 3 8 4 10 6 11 5 2 9 5 9 8 9 1 0 6 6 196

3. Kegagalan Sedasi Moderat

NOVEMBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL
Numerator 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0%
Denominator 3 6 7 2 11 3 2 3 3 4 3 0 1 3 1 2 3 2 6 0 0 5 2 4 4 8 0 0 4 0 92

4. Kejadian De-Saturasi Oksigen Pada General Anesthesi

NOVEMBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL
Numerator 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0%
Denominator 1 4 6 4 1 0 0 3 1 4 3 3 0 0 5 1 5 2 1 1 0 4 2 5 3 1 0 0 1 2 63

5. Ketidak Sesuaian antara Diagnosa Pre Operasi Dan Post Operasi

 1 1
NOVEMBER 1 2 3 4 5 6 7 8 9 10 11 13 14 15 17 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL
2 6
Numerator 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0%
Denominator 4 10 13 6 13 4 2 10 8 11 6 4 3 3 8 4 10 6 11 5 2 9 5 9 8 9 1 0 6 6 196

6. Tidak Terlaksananya Site Marking

NOVEMBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL
Numerator 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0%
Denominator 4 10 13 6 13 4 2 10 8 11 6 4 3 3 8 4 10 6 11 5 2 9 5 9 8 9 1 0 6 6 196

7. Angka Ketidaklengkapan Assesmen Pre Anestesi

NOVEMBER 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 TOTAL
Numerator 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
0%
Denominator 4 10 13 6 13 4 2 10 8 11 6 4 3 3 8 4 10 6 11 5 2 9 5 9 8 9 1 0 6 6 196