Suci Noor Hayati, S.Kep.,Ners.,M.


Health care is not safe.
During this 30 minute presentation:
• 5 – 7 patients across the U.S. will
die due to medical error or
• 85 – 113 patients will be hurt
• 21 – 29 employees will experience
a needle-stick injury

Improving Healthcare Using Toyota Lean Production Methods R. Chalice, 2007Levinson, D. R. (2008). Adverse events in hospitals: overview of key
issues. Department of Health and Human Services, Office of Inspector General. Retrieved at:
IOM (1999). To err is human: building a safer health system. Retrieved at:
Kohn, L.T., Corrigan, J.M., and Donaldson, M.S. (Eds). (2000). To err is human: building a safer health system. Committee on Quality of Healthcare in
America. Washington, DC: National Academy Press.


1. Enhance our Culture ofRSafety M 3. Identify Top Causes ofHHarm A 2. Improve the Quality and Clarity of Clinical Communications 50% 4. Redesign Care To Eliminate Harm 3 .

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D. IL: Aviation Research Lab 5 Institute of Aviation. T. von Thaden.. A synthesis of safety culture and safety climate research (Technical Report ARL-02-3/FAA-02-2). (2002). Zhang. A. H. G. .Enhancing our Culture of Safety Safety Culture Global Indicators • • • • • Komitmen organisasi Pemberdayaan Karyawan Reward Systems (Just Culture) Sistem pelaporan Kemitraan dengan pasien dan keluarga Formal Team Build Local Training Safety Champions Structure Create Safe Environments Establish a Common Language HFHS Culture of Safety Building Blocks Wiegmann. Sharma.A... and Mitchell. Savoy.

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2 improvement = statistically significant 7 .1 improvement = meaningful 0. 0.Units with Safety Champions showed improvement for all safety questions and engagement questions compared to units without safety champions.

“Coming together is a beginning. Working together is success. Keeping together is progress.” Henry Ford 8 .

• Untuk mengembangkan jaringan keselamatan pasien dengan multidisplin • Create ‘error wisdom’ at the front line • Mendukung nilai nilai keselamatan pasien untuk mendukung budaya keselamatan First Safety Champions 6/2008 9 .

     Memiliki minat yang tulus dalam keselamatan pasien Merupakan role model dalam keselamatn pasie Dihormati oleh rekan Bersedia dan mampu mengkomunikasikan informasi (tujuan keselamatn pasien. pelaporan) dalam pertemuan departemen. Front line. atau obrolan Bersedia untuk merangkul setiap peluang 10 . multidisciplinary employees that act as a “Voice” and “Face” of Safety. briefing.

2008 11 11 .Program Start: June.

profesional.Penelitian tentang faktor manusia telah menunjukkan bahwa karyawan yang sangat terampil . dan memiliki motivasi rentan terhadap kesalahan karena keterbatasan manusia yang melekat 12 12 .

13 Image Source:http://www.we generally store only partial A Simple Example of the Limits of Memory descriptions of things to be descriptions that are sufficiently precise to work 13 .Memory.

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Culture of Safety. Healthcare Equity and Culturally Competent care. Speak Out: Creating Safe Environments.Error Reporting & Error Prevention. Emergency Preparedness and Patient Safety…. Speak Up. Getting LEAN with Hand Hygiene.   2 Minute Tutorials: “How To’s” Great Catch Stories 17 17 . Quarterly Forums: Identify top causes of harm. Just Culture.

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for hospital •Selecting equipment •Post-fall survey.. management program  Project •Handicapped parking assistance •Bladder health and collaborative project •Handwashing projects •Medication review process •Mammogram process review •Medication dispensing projects •A3s-Needlestick prevention •More…. through our 19 19 .•2 patient identifier projects  Accurate and form Voluntary reporting •Revised SBAR for patient hand-offs reporting system.

000 medications orders per day Dispense 17.000 medication doses per day Recognize human limitations and have made 49 system improvements since joining the program 20 .   Process 7.

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 378 Safety Champions (multidiscplinary. multiple business units)     100% would recommend program >95% favorable with class and forum surveys 95% share toolkits and newsletters 88% believe they have made an impact on the culture of safety for their units  80% participate in safety improvement work 22 22 .

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Safety Champion I am a because I do my best to live the Henry Ford Experience of caring about people by helping to make sure they are safe.. Stephanie B. CHSP 24 ...delivering the highest spreading wellness to individuals quality care thatPatient is reliable and coordinated for the by Safety Being that are in my reach... CPP. MSN I am a safety champion because contact with me in the for our patients who depend on us Henry Ford Health when they are most vulnerable.Ruth Patient Safety means. CHSP Do Make a Difference in I want to be proactive in Patient Safety means…. everyone that comes in safe environments DO make a difference one person at a time". system..Katie Horn BSN I make a Because itsSafety Important to the I am a safety champion Patient means being proactive in creating and maintaining difference to because I CAN and Lives of ALL.…on a daily basis.Latonya Phillips Judy Czerepowicz. Northcote.. Minimizing Risk. Anderson. Injury patients we serve each day. MaryAnn L.. healthy..Judy Caretti-Rourke prevention is a key component in Proactive.the helping our loved ones and others environment I work in and the people I serve are in our community stay safe and Creating Safe Environments important to me“ LesaBorden Sanford RN.." putting forth a conscience effort to protect our patients and employees by minimizing risk and adhering to all set standards while providing the highest quality care in the safest work environment possible!!!! Dawn Dombek-Bailey. RN.... CHSP all Safety Champions Can and I make a difference in the lives of persons who enter HFHS properties.. I am a Safety Champion because.

25 .Thank You to all Safety Champions for making a difference.

the leader coaches them The boss says “I”. the leader shows how Be the boss or leader?????? “Absolutely Be a good leader” 26 .   The boss drives group members. the leader says “We” The boss know how it’s done.

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