Professional Documents
Culture Documents
Standar
Rumah sakit me-
ngembangkan
suatu
pendekatan
untuk
memastikan
tepat-lokasi,
tepat-prosedur,
dan tepat-
pasien.
Maksud dan Tujuan
Salah-lokasi, Salah-prosedur, Salah Pasien Pada Operasi, Adalah
Sesuatu Yang Mengkhawatirkan Dan Tidak Jarang Terjadi Di
Rumah Sakit, Penyebabnya :
Coumadin or Kemadrin ?
Lotrison or Lotrimin ?
www.sitemarx.com 10
SALAH ORANG, SALAH TEMPAT, SALAH
PROSEDUR PEMBEDAHAN
Factors contributing to failures
• “Captain of the Ship”
mentality
• Surgery team hierarchy
• Culture of blame and
punishment
• Compelling incentives for
speed
• Little attention to near
misses
• Failure to adopt “best
practices”
• Litigation and confidentiality
www.sitemarx.com 12
Impact of wrong site cases
• Physical injury and possibly
assault
• Loss of faith in the
healthcare providers
• Surgeon litigation and
licensure penalties
• Hospital litigation and
accreditation penalties
• Indefensible public image
risk
• Undermines surgery team
cohesion
www.sitemarx.com 13
THE JOINT COMMISSION UNIVERSAL PROTOCOL FOR
PREVENTING WRONG SITE, WRONG PROCEDURE, AND
WRONG PERSON SURGERY
14
• The Universal Protocol is based on the fact
that wrong site, wrong procedure, and wrong
person surgery can be prevented.
16
Why the Joint Commission Developed
the Universal Protocol
17
Sentinel Event Experience to Date
Of 3044 sentinel events reviewed by the Joint Commission, January 1995
through March 2005:
421 inpatient suicides
383 operative/post op complications
378 events of surgery at the wrong site
333 events relating to medication errors
225 deaths related to delay in treatment
148 patient falls
126 deaths of patients in restraints
108 assault/rape/homicide
89 perinatal death/injury
87 transfusion-related events
58 infection-related events
58 deaths following elopement
53 fires
50 anesthesia-related events
527 “other”
18
National Practitioner Data Bank; WSPE,
wrong-side/wrong site, wrong-procedure, and wrong-patient
adverse event
Types of “Wrong surgery” Cases
Wrong
procedure
Wrong patient 10%
12%
20
Root Causes of Wrong Site Surgery
(1995-2005)
Communication
Orientation/training
Patient assessment
Availability of info
Procedural compliance
OR hierarchy
0 10 20 30 40 50 60 70 80 90 100
21
Sentinel Event Trends:
Reported Cases of Wrong-site Surgery
40
30
20
10
0
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
22
Other organizations also issued
warnings on wrong site surgery.
• Statement on ensuring correct patient, correct site,
and correct procedure surgery
Bulletin of the American College of Surgeons Volume
87, Number 12, December 2002
• AAOS launches 2003 public service ad campaign
AAOS Bulletin February 2003, an American Academy
of Orthopaedic Surgeons “Sign Your Site” initiative
23
Wrong Site Surgery Events
Did Not Decrease!
Despite these efforts, the number of wrong
site surgeries reported to the Joint
Commission’s database increased.
By 2003, the Joint Commission was receiving 5
to 8 reports of wrong site surgery every
month.
24
Provisions of the Universal Protocol
25
1. VERIFIKASI SEBELUM OPERASI
Lanjutan…….
Tujuan :
• Mengidentifikasi tempat insisi atau insersi yang
benar
• Proses :
– Dilakukan untuk prosedur yg harus dibedakan :
• Sisinya ( kiri/ kanan);
• Struktur yang berbeda ( ibu jari kaki dan jari lainnya )
• Level yang berbeda ( level tulang belakang )
Penandaan
– Penandaan lokasi operasi perlu melibatkan pasien
– Tanda tak mudah luntur terkena air.
– Mudah dikenali
– harus digunakan secara konsisten di RS
– dibuat oleh operator /orang yang akan melakukan
tindakan,
– dilaksanakan saat pasien terjaga dan sadar jika
memungkinkan, dan harus terlihat sampai saat akan
disayat
– Penandaan dilakukan pada semua kasus termasuk sisi
(laterality), multipel struktur (jari tangan, jari kaki, lesi),
atau multipel level (tulang belakang).
IDENTIFIKASI PASIEN
DAN PENANDAAN LOKASI
3). “TIME-OUT” PRACTICE :