EAST JAVA PROVINCIAL GOVERNMENT

Dr. SOETOMO GENERAL HOSPITAL

Mayjen. Prof. Dr. Moestopo street Number 6-8, Surabaya, Telephone 031-550 1078, Fax 5028735,
Postcode 60286 Website www.rsudrsoetomo.jatimprov.go.id, E-mail kontak@rsudrsoetomo.jatimprov.go.id
SURABAYA
DECREE OF THE DIRECTOR OF
Dr. SOETOMO GENERAL HOSPITAL
NUMBER : 188.4/ 9263 /102.6/2022

REGARDING
POLICY OF INTERNATIONAL PATIENT SAFETY GOALS
Dr. SOETOMO GENERAL HOSPITAL

THE DIRECTOR OF Dr. SOETOMO GENERAL HOSPITAL

Has : a. That in an effort to improve the quality and safety of patient at the Dr.
Considered Soetomo general hospital , then the International Patient Safety
Goals Policy has been stipulated;
b. That in relation with the development of services and knowledge, it is
necessary to make change to the policy of International Patient
Safety Goals at the Dr. Soetomo General Hospital ;
c. That based on the considerations as referred to in letters a and b, it
is necessary to re- stipulate the decree of the Director of Dr.
Soetomo General Hospital regardding the International Patient
Safety Goals Policy at Dr. Soetomo General Hospital.

Has Born in : 1. Law of the Republic of Indonesia Number 29 of 2004 concerning

Mind Medical Practice (State Gazette of the Republic of Indonesia of 2004
Number 11, Supplement to the State Gazette of the Republic of
Indonesia Number 4431);
2. Law of the Republic of Indonesia Number 25 of 2009 concerning
Public Services (State Gazette of the Republic of Indonesia of 2009
Number 112, Supplement to the State Gazette of the Republic of
Indonesia Number 5038);
3. Law of the Republic of Indonesia Number 36 of 2009 concerning
Health (State Gazette of the Republic of Indonesia of 2009 Number
144, Supplement to the State Gazette of the Republic of Indonesia
5063);
4. Law of the Republic of Indonesia Number 44 of 2009 concerning
Hospitals (State Gazette of the Republic of Indonesia of 2009
Number 153, Supplement to State Gazette of the Republic of
Indonesia 5072);
5. Regulation of the Minister of Health of the Republic of Indonesia
Number 11 of 2017 concerning Hospital Patient Safety;
6. Decree of the Minister of Health Number 1128 of 2022 concerning
Hospital Accreditation Standards;
7. Joint Commission International Accreditation Standards for Hospitals
7th Edition 2020
HAS DECIDED…
 HAS DECIDED

To Establish :
FIRST : Policy of the International Patient Safety Goals at Dr. Soetomo General
Hospital, with the policy structure as attached in the attachment to this
decree;

SECOND : Policy of the International Patient Safety Goals at Dr. Soetomo General
Hospital, according to the FIRST dictum, is used as a reference in
administering services at the Dr. Soetomo General Hospital;

THIRD : With the enactment of this Decree, the Director's Decree Number:
188.4/2039.3/102.6/2022 regarding International Patient Safety Goals
Policy at Dr. Soetomo General Hospital declared no longer valid;

FOURTH : This decision is valid from the date of stipulation and if in the future it
turns out that there are deficiencies and errors, Corrections will be made
as accordingly;

FIFTH : A copy of this decree is submitted to the related section to known and
implemented accordingly.

STIPULATED IN : SURABAYA
ON : July 1st , 2022
DIRECTOR OF Dr. SOETOMO
GENERAL HOSPITAL

Dr. JONI WAHYUHADI, dr, Sp.BS(K)

Middle Administrator
NIP. 19640620 199003 1 007

Copy of Letter:
1. the Deputy Directors
2. related section
 Attachment
Director Decree of Dr. Soetomo General Hospital
Number : 188.4/ 9263 /102.6/2022
Date : July 1st ,2022

PATIENT SAFETY GOALS POLICY

GOALS I

Identify Patient correctly

1. The hospital develops and implements a process to improve the accuracy of

patient identification
A. For writing patient identification, hospital registration or admission officers verify the
patient's personal data with an electronic identity card (KTP), family composition card
(KSK), passport or driver's license. The sex of the patient was determined according
to these data.
B. The patient identification process used consists of at least 2 (two) of 4 (four) forms of
identification, namely :
1. Patient name
2. Date of Birth
3. Medical record number
4. Citizenship Number
C. These two (2) identities are used in all areas of the hospital's services which has been
set, namely
1. Orally / verbally identification of the patient can be carried out using the patient's
name according to the patient's KTP and date of birth
2. Verbally it cannot be done, patient identifiers are used visually, namely the
patient's name according to the KTP and medical record number.
3. There are special situations where visual patient identifiers are used, i.e. patient
name as electronic identify card or KTP and medical record number, for example:
neonates, comatose patients or patients experiencing confusion/disorientation,
during the postoperative/invasive procedure period, to label specimens, or to report
diagnostic tests and the like, breast milk labels, and corpses.
D. Not allowed to use the patient's room number or the location of the patient being
treated
E. Printed patient identification (patient identification label) is used on all drug labels,
medical records, drug prescriptions, food, specimens, request forms and results of
supporting examinations
F. Patient identification wristlets and risk identification sticker :
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 1. Patient identification wristlets consist of two (2) type, that is:
b. Pink patient wristlets for female patients
c. Blue patient wristlets for male patients
2. Risk identification sticker consist of three (3), that is:
a. Red sticker for drug allergy patients
b. Yellow sticker for patients at risk for falls
c. Purple sticker for DNR patients
3. Do not overwrite the inscription on the patient identification wristlets and risk
Identification sticker
G. Placement of patient identification wristlets and risk identification wristlets
1) Patient identification wristletss are placed on:
a. All hospitalized patients
b. IGD & special units (for patient services; Endoscopy, Urogenital
Minimally Invasive, Radiotherapy, ODC surgery, ODC children's cancer,
ODC Chemotherapy, Hemodialysis and Surgical & Invasive Units) where
in these units patients receive high-risk services and have the potential to
become unconscious at during an action or procedure.
c. Referral patients from other hospitals who will receive invasive
procedures and non-surgical
2) The patient identification wristlets is placed on the dominant extremity area, the
position of the writing on the wristlets is facing the officer / fingers.
3) Placement of identification wristletss on patients is carried out by nurses or
other health workers with education on the accuracy of patient identification
4) Installation of a risk identification sticker is carried out by a care delivery
professional (PPA) according to the usage criteria
5) For patients whose lower and upper extremity cannot be worn with an identity
wristlets, a patient with extensive burns, the identity wristlets must be attached
to the patient's body using a transparent tape
H. Patient identification wristlets should be replaced immediately if typographical errors or
damage occur.
I. Patient identification accuracy education includes:
1) Purpose and benefits of fitting an identity wristlets
2) Involvement of the patient in the identification process, that is by reminding
officers to always identify before administering drugs, before taking procedure,
diagnostic and therapeutic processes, before giving blood products, before
taking blood or specimens, before giving food to patients with special diets
3) Prohibition not to close/cross out/overwrite with writing/take off the wristlets that
has put by officer.

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J. Patient identification process
1) The patient identification process is carried out correctly when:
a. Before carrying out intervention/therapeutic procedure (for example
administering drugs, giving blood or blood products, carrying out radiation
therapy)
b. Before performing any procedure (eg placing an intravenous line or
hemodialysis)
c. Before any diagnostic procedure (eg taking blood and other specimens for
laboratory supporting examination, or before performing a cardiac
catheterization or diagnostic radiology procedure)
d. Before serving patient food

2) The patient identification process as referred to in paragraph (1) is carried out

in two (2) ways, that is:
a) Verbal, by asking the patient to state the patient's name according to the
KTP and date of birth and then the officer adjusts the information to the
patient's identity wristlets that has been attached. Verbal identification
process is done with open questions.
b) Visual, by looking at the patient's name according to the KTP and medical
record number on the patient's wristlets.
3) If it is not possible for the patient to answer, the guardian/guardian of his/her
closest family can be asked for information to verify the patient's identity.
K. Identify patients in special situations, for example; the patient is unconscious (coma),
disoriented and comes to the hospital without identity information, without a family,
then identification follows the patient's procedure without an identity. Patients in this
group will be registered by the admissions officer with the name Mr.X or Mrs. X. The
information listed on the ID wristlets includes; Mr. X or Mrs X (according to gender),
followed by the date, month of registration and the approximate age of the patient to
determine the year of birth as the identity of the date of birth, as well as the medical
record number. If in the future the patient's identity can be identified, the patient's
identity information will be revised by the admissions officer and then the patient will
be given a new ID wristlets that is valid as usual.
L. When disaster emergency occurs, patient identification use Mr. X1, Mr.X2 and so on or
Mrs.X1, Mrs.X2 according to the time of registration and gender, followed by the date,
month of registration and the estimated age of the patient to determine the year of
birth as the identity of the date of birth, as well as the medical record number. If in the
future the patient's identity can be identified, the patient's identity information will be
revised by the admissions officer and then the patient will be given a new ID wristlets
that is valid as usual
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M. An identity wristlets was prepared by the admissions officer and then put on by the
nurse on duty. Except for the baby's mother's wristlets which can be directly prepared
by the midwife in the delivery room and operating room where the baby is born.
N. Provision of identity to newborns in the hospital: as soon as the baby is born, the
midwife or nurse in the delivery room or operating room (depending on where the
baby's birth occurs) immediately registers the printed mother-infant wristlets. The
mother-baby wristlets is a special pair of wristlets for mothers and newborns. Then the
baby will be attached to the ID wristlets on the leg. Furthermore, the baby's mother
also has this special wristlets attached. The baby's name temporarily follows the
mother's name, for example By. Mrs. Mother's name.
O. How to identify twins: ID wristletss are given equally between the baby and the mother
giving birth, with the identity of each baby being given the time of birth
P. How to identify conjoined twins: The ID wristlets is given equally between the baby and
the mother who gave birth. If born in a hospital, the 1st baby is given the identity
By.Ny. The names of the 1st mother and 2nd baby are identified as By.Ny. 2nd
mother's name (example; By Mrs. Aminah 1, By. Mrs. Aminah 2) . If born outside the
hospital, the baby's identity wristlets matches the baby's name.
Q. The staff (nurse or midwife) in the room must replace it with a new wristlets if it is
damaged, the writing is not clear or it is lost. If there is the same name in the ward, it
must be informed to the nurse on duty every time the shift changes and place the
patient not side by side (strive to have different rooms).
R. Any patient who refuses to wear an identification wristlets, must be notified by the
officer that he or she will not be able to provide the prescribed treatment. This incident
must be clearly documented in the patient's medical record and a safety incident
report must be submitted to KMKP.
S. Removal of patient identification wristlets:
1) Removing the patient's identity wristlets is done on:
a. The patient goes home
b. Post-anyprocedural treatment patients in non-hospitalization
c. Patients died in care period
2) Removing the identity wristlets on a deceased patient is carried out in the
mortuary by officers from the Medicolegal Forensic Medicine Installation
(IKFM).
3) Removal of the wristlets must be cut into several pieces and disposed of in the
medical waste bin.

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 Goals II

Improving Effective Communication

2. The hospital develops and implements a process to increase the effectiveness of

verbal and/or telephone communication among care providers.
A. The use of verbal and/or telephone communication using the SBAR method
(Situation, Background, Assessment, Recommendation). This method is carried out
during handovers between shifts, between units and when contacting the the doctor
in charge of the patient (DPJP) to report: :

1) New patient admitted to hospital

2) Patients with critical condition..
3) Patients who have a critical value of supporting examination results
4) Conditions that require close monitoring.

B. The Write, Read, Confirm (TBAK) method is used if there is verbal and/or telephone
communication:
1) Submission of critical diagnostic examination results
2) Oral and/or telephone orders or instructions.

C. Oral instructions are documented in the TBAK file in the electronic medical record
(EMR) and must be verified within a maximum of 1X24 hours by the order giver
(DPJP).
D. Telephone instructions are documented in the TBAK file in the electronic medical
record ( EMR ) and must be verified within a maximum of 1X24 hours by the order
giver ( DPJP ).
E. The complete results of the examination are documented and re-read by the
recipient of the message and confirmed by the officer who reported the results.
F. The health worker who can give verbal instructions over the telephone is the doctor
in charge of service (DPJP).
G. Health workers who can receive verbal instructions via telephone are doctors on
duty, nurses in charge of services (PPJP), associate nurses, pharmacists and
dietitians.
H. For instructions by telephone related to LASA, the recipient of the message must
spell the name of the drug in the phonetic alphabet.
I. Ordering drugs and or ordering drugs verbally is avoided, except in an emergency
because written communication or electronic communication is not possible

5
2.1 The hospital develops and implements a process for receiving critical
results and diagnostic examination
A. The hospital determines the amount of critical laboratory values / vital signs and
the results of critical diagnostic examinations which include
1) Clinical Pathology Examination
2) Clinical Microbiology Examination
3) Pathological Anatomical Examination
4) Diagnostic Radiological Examination
5) Electrocardiogram Examination
6) Vital Signs Value
Vital signs include: blood pressure, pulse, temperature, respiration and pain.
Vital signs will be converted to the Early Warning System (EWS) interpretation.

B. The list and amount of critical values for each type of diagnostic examination are
determined as contained in the attachment to this policy.
C. Every critical laboratory examination result / critical diagnostic examination result
must be immediately verified by the Doctor in Charge of Medical Engineering
(DPJTM).
D. Any critical vital sign values must be immediately reported to the doctor on
duty/DPJP.
E. The deadline for submitting critical laboratory and radiodiagnostic values is no
later than 30 minutes, except for the results of the ECG examination within 5
minutes (the time limit is calculated from the verification of critical results by the
DPJTM until the critical value information is received from the DPJP or the
Doctor on Duty).
F. The results of critical diagnostic examinations are documented by the recipient
of the information in the SOAPIE electronic medical record (EMR). In the
objective (O) column, the record is written as the recipient's time, the type of
critical result and the name that provides the information. Recipients of critical
results in rooms and polyclinics are nurses and immediately report to the DPJP
or doctor on duty. Outside working hours for outpatient critical results will be
immediately conveyed to the patient / family and educated to come immediately
to the emergency room to check.
G. Communication when reporting critical results of diagnostic support
examinations via telephone: writing / inputting to a computer, reading out,
confirming again and documenting it in the medical record.
H. Recipients of critical laboratory and radiodiagnostic results immediately submit
to the DPJP for follow-up. Reporting of recipients of critical results to the DPJP /

6
 doctor on duty applies according to the provisions for verbal / telephone
reporting
I. Each POCT (Point of Care Testing) laboratory examination result must be
reported to the Central Laboratory. These results will be validated by the Central
Laboratory / DPJTM. The central laboratory will send the results of the
examination through the Laboratory Information System (LIS) so that they can
be read back by the DPJP or the doctor on duty in the room. The critical value of
the POCT examination results refers to the hospital's critical value setting policy.
If the POCT results show a critical value, the DPJTM will report it to the DPJP or
the doctor in charge of the room according to the critical value reporting
procedure.
2.2 The hospital develops and implements a communication process for
handovers
A. Handover of hospitalized patients, includes
1. Between care delivery Professional PPA such as doctors and doctors,
between nursing staff and nursing staff during shift exchanges
2. Antar berbagai tingkat layanan di rumah sakit seperti : pasien dipindah dari
unit intensif ke unit perawatan, pasien pindah antar unit , dari unit
perawatan ( low care) ke kamar operasi and dari unit darurat ke kamar
operasi
3. Between various levels of hospital services such as: patients are transferred
from the intensive care unit to the care unit, patients move between units,
from the care unit (low care) to the operating room and from the emergency
unit to the operating room
4. From inpatient units to diagnostic service units or action units such as
radiology or endoscopy.
5. From diagnostic service units or action units such as radiology or endoscopy
to inpatient units
6. Between staff and patients/families, such as on discharge
B. Handover of patient care between nursing shifts and doctors is carried out in the
ER and all hospitalizations include critical matters
C. Critical matters that need to be handsover are: critical diagnostic examination
results, increased EWS, plans for using inotropic drugs (Dopamine,
Dobutamine), correction plans for critical diagnostic examination results:
hyperkalemia, hypokalemia, hypernatremia, hyponatremia, hyperglycemia ,
hypoglycemia, anemia, thrombocytopenia, plans to move rooms, plans for
action/surgery, plans for consuls, plans for diagnostic examinations and taking
the results.

7
D. The process of handover of patient care between shifts critical matters are
documented in the SBAR medical record of handover between shifts using a
report book that shows who handed over and who received.
E. The process of handover of patient care (handover) is carried out between
various levels of service in in the hospital is documented in the patient transfer
medical record.
F. Handover evaluation is carried out by nurses and doctors who received
handover from the previous shift to assess the handover process according to
what was handed over or if there were critical problems that were not handed
over from the previous handover process.
G. If during the handover evaluation there is a communication error or an action
that is not handed over ends up causing injury to the patient / KTD a safety
incident report will be made and efforts to repair the conditions when the
handover process occurs

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 Goals III
Improving the Safety of High Alert Medications

3. The hospital develops and implements a process to improve the safety of use high-
alert medications.

1. The hospital develops and implements a process to improve the safety of LASA
(look-alike/sound-alike) medications.

2. The hospital develops and implements a process to manage the safety of use
electrolyte concentrates

A. High alert drugs or drugs that need to be watched out are drugs that have a high
percentage of errors and or sentinel events, as well as drugs with a high risk of
abuse or misuse.
B. The high alert drug management policy covers all hospital leadership and staff, to
increase awareness of high alert drugs and improve patient safety. All Dr. Soetomo
General Hospital’s leaders and staff must have a commitment to provide high
quality health services and minimize the occurrence of medical errors and reduce
potential risks to patients.
C. The hospital establishes guidelines and standard operating procedures for the
purposes of implementing policies related to the high alert drug management
process
D. The hospital establishes a list of high risk drugs and electrolyte concentrates
through the hospital's Pharmacy and Therapeutic Committee
E. The Pharmacy Installation makes a list of LASA drugs and reviews them
periodically.
F. High alert medication consists of :
1. High Risk Drug
a. Injectable magnesium sulfate with a concentration of20% and 40%
b. Injection Sodium bicarbonate
c. Insulin (all medicinal preparations)
d. Anti - coagulants (Heparin injection)
e. Adrenergic agonist (injectable Epinephrin, injectable Norepinephrin)
f. Narcotics injection (injectable Morphine, Injectable Pethidine, Injectable
Fentanyl, Injectable Remifentanil, Injectable Sufentanil)
g. Sedative Injection (Midazolam Ijection)
h. Injection Anesthetics (Injection Propofol , Injection Ketamine)

9
 i. Injection cytostatics
- Ibandronat acid 1mg/mL
- Zoledronat Acid 4mg/100mL
- Asparaginase 10000IU/vial
- Bleomycin 15mg/mL
- Dacarbazine 200mg/mL
- Clodronate Disodium 300mg/5mL
- Doxorubicin 10mg and 50mg
- Dosetaxel 20mg and 80mg
- Epirubicin 10mg and 50mg
- Etoposide 20mg/mL
- Fludarabine 50mg
- Fluorouracil 50mg/mL
- Gemcitabine 200mg and 1000mg
- Goserelin Acetate 3.6mg and 10.8mg
- Ifosfamid 1000mg and 2000mg
- Irinotekan 20mg/mL
- Calcium Folinate 50mg/mL
- Carboplatin 450mg/45mL and 150mg/15mL
- Lenograstim 263mcg/mL
- Leuprolelin acetate 3,75mg and 11.25mg
- Mesna 100mg/4mL
- Metotrexate 25mg and 50mg
- Oxaliplatin 100mg and 50mg
- Octretide 20mg and 30mg
- Paclitaxel 30mg, 100mg and 300mg
- Pemetreset 500mg
- Rituximab 100mg and 500mg
- Setuximab 100mg
- Cyclophosphamide 500mg and 1000mg
- Cysplatin 10mg and 50mg
- Cytarabine 100mg
- Vincristine 2mg and 1mg
- Vinorelbin 10mg/mL and 50mg/5mL
2. Concentrated electrolyte
a. NaCl > 0,9%
b. KCl 7,46% injection
c. Sodium phosphat ≥ 3mmol/mL

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 LASA Drug (Look alike sound alike), which is a drug that has a similar name, looks
or sounds to other drugs
4. Storage
a. High-risk drugs and electrolyte concentrates are separated from other routine
medicines, placed in limited and accessible places. Storage cabinets for high risk
drugs and concentrated electrolytes are marked with a red scotlet and are given a
High Alert sticker
b. Each drug preparation is given a special label
i. For ampoules

or

ii. For vials or flasks

iii. For cytostatic preparations

OBAT KANKER
HARUS DITANGANI

c. Concentrated electrolytes may only be stored in Pharmaceutical Warehouses, Sterile

Preparation Dispensing Units and Pharmaceutical Service Units (UPF).
d. The room can store diluted concentrated electrolytes
e. LASA drugs are given LASA special labels and High alert if in the location or local
storage area there is a resemblance to the drug, labeled with the name of the drug
according to the Tall man letter (for drugs that have similar names and
pronunciations), and kept away from similar drugs for at least 1 Medicine storage box

or
f. Multiple strength drugs must be given a colored label in the shape of a box that reads
"MULTIPLE STRENGTH" on the drug storage container and placed at least 1 box of
medicine apart from one another. If the drug has a different strength, the highest
dose is labeled with a red background, the middle dose is yellow, the next dose is

11
 green and the low dose is white. If a drug has only two dosage strengths, the highest
dose is labeled with a red background and the lower dose is labeled with a yellow
background.

5. Preparation and Submission

- Preparation of high alert drugs in the room is carried out by a doctor or clinical nurse at
least level 2
- Double check and double initial are done on time:
 Preparation of high alert drugs (high risk category and concentrated electrolytes)
 Delivery of high alert drugs from pharmacists to outpatients
- Delivery of high alert drugs from pharmacists to clinical doctors/nurses at least level 2
for inpatients/ER

6. Administration
a. Administering high alert drugs to inpatients is carried out by clinical doctors/nurses at
least level 2 on delegations of doctors, who are competent and skilled, or competent
doctors/PPDS doctors under the supervision of the Supervisor/Doctor in Charge of
Services,
b. Double check and 5 correct verifications (correct patient identity, correct drug name,
correct dose, correct route of administration and correct time of administration) must
be carried out before giving the drug High alert to prevent drug administration errors
which can be fatal
c. Doctors/nurses who give high alert drugs (high risk categories and electrolyte
concentrates) give double initials at:
- Record Sheet for Drug Administration / RPO (RM11)
- RPO Sheet for Injection Medicine/Injection Cytostatic Medicine (RM11b K)
- Intensive Care / High Care Sheet (RM 07a K): for patients in the intensive care and
high care rooms and put a circle symbol outside the cross when the drug is given
()

7. Monitoring

If an error occurs in administering the High Alert drug related to the Unwanted event/Near
miss incident case, the officer must report it to the hospital's patient safety team

12
 Goals IV

Ensuring Surgical Safety.

3. The hospital develops and implements a process for preoperative verification and
operative/invasive site marking.
A. Areas that can perform surgical and or invasive procedures include:
1) Central Surgical Installation (IBP) operating room
2) Operation Room Emergency Room (IGD Floor 5)
3) PPJT cardiac surgery operating room unit
4) Cathlab Unit
5) Endoscopy Unit and Pulmonary Action Unit
6) URJ Surgery room 4th floor
7) Gilut Installation Action Room
8) Urogenital Invasive Installation (IIU)
9) Action room in the Radiodiagnostic & Radiotherapy room
10) Graha Amerta Obgyn & Fertility Action Room.
11) STOC operating room
B. The hospital implements a preoperative verification process before any surgical or
invasive procedures are performed. This process is carried out and documented in
the medical record of preoperative verification and surgical safety check-in. This
verification is carried out in the room (before the patient is sent to the operating
room) up to the operating preparation room (premedication room). This verification
ensures that:
1) The actions are in accordance with the contents of the informed consent
2) Verify correct patient, correct action and correct location
3) All document requirements, blood products, medical equipment, and
medical device implants are available and functioning properly.
C. Verification before surgery regarding the correctness of the patient is carried out by
confirming the patient's identity (according to IPSG 1 policy), correctness of the
action is carried out by checking the suitability of the actions listed in the informed
consent form with the medical record of the preoperative assessment, verification of
blood products and implants is carried out by looking at the compatibility direct
relationship between available blood and implants and those listed in the
preoperative assessment.
D. Correct site marking should be determined when the procedure is scheduled.
Marking of the operating area (site marking) in surgical or invasive procedures is
carried out by the individual who will carry out the procedure (the operator or doctor

13
 in charge of the operation). PPDS can carry out site marking if the PPDS will carry
out all actions (act as a doctor operator) that require minimal supervision from the
doctor in charge of the operation. Site marking is a sign (√) in a circle.
E. Time marking is done before the patient enters the operating room or invasive
procedure room. What is meant by before the patient enters the operating room or
invasive procedure room is marking done in the room before being sent to the
operating room, or done in the preoperative waiting area in cases of emergency
surgery, outpatient/one day care, and invasive procedures.
F. Marking the correct location of the operation must be recorded in the medical record,
done on the same side near the surgical incision using a permanent marker that
does not fade against povidone iodine and alcohol to keep the mark visible after the
patient is stored and covered with cloth (drapping).
G. Site marking is carried out with the involvement of the patient. Marking conditions
where patients are not allowed to participate, for example; patients who require
emergency surgery, patients with decreased or unconscious consciousness, who
are not competent to make decisions (patients are children or aged ≤ 18 years) then
the marking must be accompanied by a family/guardian.
H. Procedure for marking the operating area (site marking), including at least marking
on:
1) All cases involving laterality,
2) Bilateral organs
3) Double structure (fingers or toes)
4) Or several levels (spine).
I. Marking of the operating area (site marking) is not necessary in cases of covering:
1) Cases of one organ/single organ (eg, cesarean section, heart surgery,
circumcision, etc.).
2) Intervention cases (eg, Prostate TUR, laryngoscopy, laparoscopy, esophageal
examination).
J. If it is not possible to mark the location of the operation, then the marking can be
done on an X-ray and drawn in the medical record.
K. Special marking procedures are carried out on:
1) Procedures for babies that require invasive procedures, where marking will
result in permanent tattoos, are marked on X-rays and drawn in the Medical
Record.
2) Cases of burns do not need to be marked on the location on the body but done
in the medical record.
3) In patients with surgical or invasive dental and oral procedures, marking is done
on dental images (odontogram) in the medical record. Marking in the form of (√)

14
 in a circle at the location to be operated on and confirmed to the patient before
surgery.
L. Time marking is done before the patient enters the operating room or invasive
procedure room. What is meant by before the patient enters the operating room or
invasive procedure room is the marking done in the room before being sent to the
operating room, or done in the preoperative waiting area in cases of emergency
surgery, outpatient/one day care, and invasive procedures.
M. Marking the correct location of the operation must be recorded in the Medical
Record, carried out on the same side near the surgical incision using a permanent
marker that does not fade against povidone iodine and alcohol to keep the mark
visible after the patient is prepared and covered with cloth (drapping).
N. Site marking is carried out with the involvement of the patient. Marking conditions
where patients are not allowed to participate, for example; patients who require
emergency surgery, patients with decreased or unconscious consciousness, who
are not competent to make decisions (patients are children or aged ≤ 18 years) then
the marking must be accompanied by a family/guardian.
O. If it is not possible to mark the operation site, then the marking can be done on an X-
ray and drawn in the medical record.
P. Special marking procedures are carried out on:
1) Procedures for babies that require invasive procedures, where marking will result
in permanent tattoos, are marked on X-rays and drawn in the medical record.
2) Cases of burns do not need to be marked on the location on the body but done in
the medical record.
3) In patients with surgical or invasive dental and oral procedures, marking is done
on dental images (odontogram) in the medical record. Marking in the form of (√) in
a circle at the location to be operated on and confirmed to the patient before
surgery.

4.1 The hospital develops and implements a time-out process to be carried out
immediately before surgery/invasive procedures are started and for a sign-out
process to be carried out after the procedure is completed.
A. The hospital adapts and implements the Surgical Check-in by referring to the WHO
version of the Safe Surgery Safe Life Guidelines in 2009. In general, surgical check-
in activities include the following processes: sign-in, time-out and sign-out.
B. The surgical review process is carried out to create process uniformity in improving
quality and safety in surgical / invasive services. The entire surgical review process
is documented in the electronic medical record of the surgical checklist. The time

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 recorded in the surgical review process is the time according to the clock in the
operating room (OK hours).
C. The sign-in stage is carried out by the nurse and the anesthesiologist before
induction of anesthesia is carried out including the components:
1) Patient identity
2) Confirm the patient's allergy history
3) Ensure that the patient and family have signed informed consent and consent
for anesthesia
4) Ensuring drugs and anesthetic machines, cardiopulmonary machines
(especially for heart surgery) and other special medical equipment are
complete and functioning properly.
5) Ensure patient clinical risks and risks in the event of an emergency during
and after surgery or invasive procedures.
D. The Time-out stage is carried out at the operating site just before the start of a skin
incision or arterial/venous puncture involving all members of the surgical team or the
invasive procedure team
E. The team present must be actively involved during the time-out process. After the
time-out is completed by the team, team members are not allowed to leave the
room. Patients are not allowed to participate in this time-out process.
F. During the time-out the team must agree on the following components;
1) Correct patient identification
2) Correct the procedure to be carried out
3) Correct location of surgical/invasive procedures
G. The entire time-out process is documented in the surgical review medical record.
The documentation includes the following components; date and time of starting
time-out, team present, accuracy of patient identity (name & medical record
number), procedure and where the incision was made, prophylactic antibiotics,
position on the operating table, anticipation of critical conditions and blood loss,
special conditions in patients related to anesthesia , sterility of tools and implants,
equipment problems that may occur, photos/images that have been shown, the
amount of gauze prepared, confirmation to the team whether the operation/invasive
procedure can be started, the date and time the time-out ends, and the signature of
the surgical and anesthesia team.
H. Time-out process just before surgery/invasive action is carried out in the operating
room area and medical action unit other than the operating room, which allows
modification or adjustment of medical record forms for surgical viewing which
includes sign-in, time-out, sign-out for surgical/invasive actions outside the operating
room (local time-out).

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I. Agreement or confirmation of starting the incision begins with prayer and the
approval of all team members by saying the word "agree”.
J. Surgical view in the unit or area outside the operating room includes: general
surgery room at the 4th Floor Outpatient Installation, Oral Dental Installation Action
Room, Urogenital Invasive Installation (IIU), Pulmonary action unit, Endoscopi,
Action room in the radiodiagnostic room and radiotherapy, emergency room, which
does not use sedation and narcotics will use a surgical checklist model that is in
accordance with local needs so that it is not the same as the form used in the
operating room.
K. The sign-out process is started by the surgical nurse as a team member doing
verbal confirmation with the following components;
1) The name of the operation/invasive action recorded
2) Completeness of instrument calculations, gauze and needles if any.
3) Labeling of specimens (when there is a specimen, then during the sign-out
process the label must be clearly read out as the patient's identity; name and
medical record number).
4) Equipment problems that need to be addressed
5) Conscious recovery issues that may be of concern.

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 Goals V
Reducing the Risk of Healthcare-Associated Infections

5.1 Hospitals adopt and implement evidence-based hand hygiene guidelines to

reduce the risk of healthcare-associated infections
5.2 The hospital identifies care processes that need improvement and adopts and
implements evidence-based interventions to improve patient outcomes and
reduce the risk of hospital-associated infections.
A. Using the latest hand hygiene guidelines according to 5 when carrying out the
five moment hand hygiene practice referring to the latest hand hygiene guidelines
from the World Health Organization (WHO) 2009.
B. In accordance with the five moments for hand hygiene, health practitioners must
get used to hand hygiene when; before contact with patients, before carrying out
aseptic procedures, after contact with patient body fluids, after contact with
patients and after making contact with the hospital patient environment.
C. Documentation of hand washing activities includes:
1) Compliance with Hospital Hand Hygiene Survey (conducted by IPCN)
2) Survey of work unit quality indicators (conducted by local work unit quality
champions)
3) Proposed requests for hand washing facilities
4) Report on the results of the patient safety walkround or SKP round
D. The hospital implements an effective hand hygiene program through promotion,
socialization and staff education programs, provision of hand hygiene facilities
and evaluation.
E. The hospital establishes standard operating procedures for the purposes of
implementing policies related to the hand hygiene process.
F. The hospital identifies and implements evidence-based interventions such as:
1) Bundle urinary tract infection associated with catheter placement (CAUTI)
2) Bundle bloodstream infection in central venous catheter (IADP)
3) Bundle pneumonia associated with ventilator placement (VAP)
4) Bundle surgical site infection (IDO)
G. Associated with severe sepsis bundles. The placement of inpatients is adjusted
to the patient's condition (infectious patients treated in the isolation room,
immunocompromised patients in the Cancer Service Development Center room,
critically ill patients treated in the ICU), so that the bundle follows the infectious
cases that occur in the patient.
H. The hospital establishes standard operating procedures for the purposes of
implementing policies related to the hand hygiene process.

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 Goals VI
Reducing the Risk of Patient Injury Due to Falls

6. The hospital develops and implements a process aimed at reducing the risk of
patient injury from falls for inpatients
A. Fall prevention includes:
1) Fall risk assessment
2) Management of risk reduction based on the results of the assessment.
3) Fall risk education
4) Evaluation of the implementation of fall risk reduction and patient fall
incidents
B. Identify the type of patient population that has factors that increase the risk of
falling including:
1) Condition and diagnosis of the patient
2) Functional impairment of the patient (eg balance disturbances, visual
disturbances, or changes in cognitive status)
3) Location (eg a physical therapy unit that has a lot of specific equipment used
by the patient which can increase the patient's risk of falling) or hospital
environment (eg patient arrival by ambulance, transfer of patient from
wheelchair or gurney).
4) History of the patient falling.
5) Consumption of certain drugs
6) Consumption of alcohol
C. The process of assessing inpatient services will assess the risk of falling (fall risk
assessment) according to the applicable scale. The applicable fall risk patient
rating scale is:
1) Morse Fall Scale for inpatient adult patients
2) Humpty Dumpty Scale for pediatric patients (age ≤ 18 yrs)
3) Admonson's scale for psychiatric patients.
4) The Sydney scale for geriatric patients follows the provisions of the initial
nursing assessment
D. The fall risk assessment includes a process:
1) Initial assessment: carried out at the initial admission of the patient to the
hospital after the initial nursing assessment was carried out
2) Follow-up assessment: carried out in the form of monitoring non-risk/low-risk
patients every 24 hours, high-risk falls every 8 hours
3) Re-assessment is done on the patient;
a. Transferred from one treatment unit to another treatment unit.
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 b. Changes in the patient's condition (for example: surgery and/or
anesthesia, medication adjustments)
c. After experiencing a fall.
E. Neonates are considered a high risk group so they are treated and managed as
high risk patients fall.
F. Fall risk management, namely identified patients, interventions such as:
1) Raising the safety rail of inpatient beds
2) The wheels of the bed are locked
3) Patients / families are given education on how to reduce or prevent patients
from falling
4) Documented in the medical record
5) Especially in patients with a high risk of falling coupled with:
a) Labeling fall risk on the ID bracelet.
b) Yellow triangular sign on the bed.
6) In anxious/mental disorder patients, 3-point fixation can be carried out with
flannel cloth with the approval of the family and an assessment and
monitoring of restraint can be carried out.
G. If there is an incident where the patient falls, then do:
1) Evacuate the patient to a safe place
2) Observation of the patient's condition to find injuries / wounds
3) Collection of incident information and documented in the CPPT, including
date and time of fall, patient description of the fall, observations/vital signs
4) Reassessment of fall risk
5) Report incidents to the Patient Safety Sub Committee in accordance with the
procedures for reporting patient safety incidents.
H. In patients admitted to Hemodialysis, management of the risk of falling following
hospitalization. All Hemodialysis patients are categorized at high risk of falling.
I. The hospital develops a patient fall prevention program that aims to reduce the
incidence of patient falls including efforts, among others:
1) Patient safety rounds
2) Monitoring falls
3) Guidance on patient assessment technique falls

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7.1 The hospital develops and implements a process to reduce the risk of patient
injury from falls for outpatients
A. Outpatients with fall risk criteria, including; patients with walkers, geriatric patients
who are weak, or walk weakly/unsteadily, limb weakness, or visual impairment
are screened for fall risk when they come to the hospital.
B. Screening is carried out by trained officers which include; security officers,
information officers, transporters, doctors and nurses on duty in the hospital
lobby area.
C. The screening is visual in nature, that is, it is carried out with the “Modified Get
Up and Go Test” assessment. Where by looking; gait/gait and the presence of a
walker
D. Outpatient screening procedures are not carried out in the group of pediatric
patients less than 2 years old, because they will be directly included in the fall
risk group.
E. Patients who enter the emergency room fall risk management follow outpatient
care.
F. Patients with screening results are at risk of falling, they will be treated as follows:
1) Given a yellow band on the upper arm for outpatient care and a yellow
sticker for the emergency department as a marker for falling risk patients.
2) Providing a fast track card for patients with conditions generally requiring
speed of service, which includes but is not limited to; weak, disabled,
moderate and severe pain.
3) Assisted by transfer services if the patient needs either a wheelchair or a
stretcher.
G. Groups of patients requiring transfer services include:
1) Patients with difficulty walking alone (foot defects, visual impairment,
neurological disorders, under the influence of drugs which have the side
effect of depressing consciousness).
2) Do not have walking aids if the patient's condition requires assistance.
H. Documentation of outpatient fall risk screening:
1) Documentation of screening results is carried out by nurses in each
outpatient service unit by paying attention to gait and walking aids.
2) The results of the screening and intervention are documented in the medical
record of outpatient services
I. Perform interventions for patients who are at risk of falling:
1) Provide a wheelchair or offer a stretcher if the patient requires it. Wheel chair
or gurney if used, lock the wheel and raise the safety rail.

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 2) Provide education to patients so they don't hesitate to ask for help from
officers or companions when they are going to carry out activities while in the
hospital, for example; going to the toilet.
3) Provide education to the patient's companion (caregiver) to always
accompany and assist the patient's activities while in the hospital
J. Inform the patient / family to remove the yellow tape and throw it in the medical
waste bin (yellow bin) when the patient is leaving the hospital.

DIREKTUR RSUD Dr. SOETOMO

Dr. JONI WAHYUHADI, dr.,Sp.BS(K)

Middle administrator
NIP. 19640620 199003 1 007

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