You are on page 1of 59

SASARAN KESELAMATAN PASIEN KE IV : KEPASTIAN TEPAT-LOKASI,

TEPAT-PROSEDUR, TEPAT-PASIEN OPERASI

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 :

1. Komunikasi Yang Tidak Efektif/Tidak Adekuat Antara Anggota


Tim Bedah
2. Kurang/Tidak Melibatkan Pasien Di Dalam Penandaan Lokasi
(Site Marking)
3. Tidak Ada Prosedur Untuk Verifikasi Lokasi Operasi
4. Asesmen Pasien Yang Tidak Adekuat
5. Penelaahan Ulang Catatan Medis Tidak Adekuat
6. Budaya Yang Tidak Mendukung Komunikasi Terbuka Antar
Anggota Tim Bedah
7. Resep Yang Tidak Terbaca (Illegible Handwriting)
8. Pemakaian Singkatan
MASALAH PEMBEDAHAN
• Salah pasien
• Salah lokasi operasi
• Salah prosedur
• Tertinggalnya benda asing dalam tubuh
pasien
Preventable Adverse Events
100,000 die from medical errors
Does not include:
- wrong site
- retained surgical item
- surgical site infection with hypothermia
- cancer recurrence with blood transfusion
- consequences of hyperglycemia

15,000,000 harms - IHI


Poor handwriting

Coumadin or Kemadrin ?
Lotrison or Lotrimin ?

Doxorubicin or Daunorubicin ? Pentobarbital or Phenobarbital ?


Wrong site surgery:
The frequency debate
– 1 in 5,000 – 10,000 cases
– Not an accepted risk of surgery
– Near misses not tracked
– Near misses not analyzed
– Numbers debate undermines public trust
– Corrective efforts compromised by the numbers
debate

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.

• It is based on a consensus of experts and is


intended to achieve the goal of eliminating
wrong person, wrong procedure, and wrong
site surgery.
“An orthopedic surgeon has a 1 in 4 chance
of performing a wrong site surgery during a
35 year career.”
AAOS Task Force, 1997

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%

Other wrong Wrong side


site 59%
19%

20
Root Causes of Wrong Site Surgery
(1995-2005)
Communication

Orientation/training

Patient assessment

Availability of info

Procedural compliance

OR hierarchy

Distraction Percent of events

0 10 20 30 40 50 60 70 80 90 100

21
Sentinel Event Trends:
Reported Cases of Wrong-site Surgery

100 W.S.S. Summit


90 NPSGs May 2003
January 2003 U.P.
80 S. E. Alert #24
December 2001
70
60
S. E. Alert # 6
50 August 1998

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

• Preoperative verification process

• Surgical site marking

• “Time out” immediately before starting

• Applicable to invasive procedures in all


settings

25
1. VERIFIKASI SEBELUM OPERASI
Lanjutan…….

Maksud proses verifikasi praoperatif adalah untuk :


• Memverifikasi lokasi, prosedur, dan pasien yang benar
• Memastikan bahwa semua dokumen, foto (imaging), hasil
pemeriksaan yang relevan tersedia, diberi label dengan baik, dan
dipampang
• Melakukan verifikasi ketersediaan peralatan khusus dan/atau
implant 2 implant yg dibutuhkan
• Tahap Time out memungkinkan semua pertanyaan atau kekeliruan
diselesaikan
• Time out dilakukan di tempat, dimana tindakan akan dilakukan,
tepat sebelum tindakan dimulai, melibatkan seluruh tim operasi. RS
menetapkan bgmn proses itu didokumentasikan secara ringkas
misal: menggunakan ceklist.
VERIFIKASI DOKUMEN
2. PENANDAAN (MARKING SITE) LOKASI OPERASI

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 :

• Benar pasien, benar lokasi operasi/


tindakan, benar prosedur tindakan dan
keberadaan implants/ equipment ==>
sebelum operasi dimulai
• Gunakan Surgical Safety Checklist dari WHO
Patient Safety (2009)
TIME OUT PRACTICE
• DILAKUKAN SEGERA SEBELUM DILAKUKAN PROSEDUR
• TUJUAN :
– MELAKUKAN VERIFIKASI AKHIR BENAR PASIEN, BENAR LOKASI,
BENAR PROSEDUR/ TINDAKAN OPERASI
• PROSES :
– KOMUNIKASI AKTIF OLEH SEMUA ANGGOTA TIM
PEMBEDAHAN/ YG AKAN MELAKUKAN PROSEDUR (
PERAWAT, DOKTER BEDAH, DOKTER ANESTESI,
PERAWAT ANESTESI )
– PROSEDUR TIDAK BOLEH DIMULAI SEBELUM SEMUA
MASALAH/ PERTANYAAN DAN KEKHAWATIRAN
TERKAIT PASIEN DISELESAIKAN DAN MENDAPAT
PENJELASAN SECARA MENYELURUH
TIME OUT
PRACTICE
TIME OUT
TIME OUT
Sebelum Induksi Anestesi:
Apakah……

1. Identifikasi pasien, prosedur,


informed concent sudah dicek ?
2. Sisi operasi sudah ditandai ?
3. Mesin anestesi dan obat-obatan
lengkap ?
4. pulse oxymeter terpasang dan
berfungsi ?
5. Allergi ?
6. Kemungkinan kesulitan jalan
nafas atau aspirasi
7. Risiko kehilangandarah >= 500ml
Sebelum Insisi Kulit (Time-
out):Apakah …….
1. Konfirmasi anggota tim (nama dan peran)
2. Konfirmasi nama pasien , prosedur dan lokasi
incisi
3. Antibiotik propillaksi sdh diberikan dalam 60
menit sebelumnya
4. Antisipasi kejadian kritis:
1. Dr Bedah: apa langkah, berapa lama, kmk blood lost
?
2. Dr anestesi: apa ada patients spesific corcern ?
3. Perawat : Sterilitas , instrumen ?
5. Imaging yg diperlukan sdh dipasang ?
Sebelum Pasien Meninggalkan Kamar
Operasi
1. Perawat melakukan konfirmasi secara verbal,
bersama dr dan anestesi
1. Nama prosedur,
2. Instrumen, gas verband, jarum lengkap
3. Speciment telah di beri label dengan PID tepat
4. Apa ada masalah peralatan yang harus ditangani
2. Dokter kpd perawat dan anesesi, apa yang harus
diperhatikan dalam recovery dan manajemen pasien
TERTINGGALNYA BENDA ASING
• Sebagian besar dapat
dikeluarkan dari tubuh
pasien ==> sembuh total
• Mortalitas berkisar 11-35
% ==> perforasi : usus,
kerusakan organ, sepsis ,
nyeri akut
FAKTOR YG MENYEBABKAN
TERTINGGALNYA BENDA ASING ==>
TUBUH PASIEN
• Prosedur darurat
• Jenis prosedur
• Perubahan rencana operasi semula
• Berat badan pasien
• Kegagalan penghitungan selama pembedahan
atau penghitungan tidak akurat
APA YANG HARUS DIHITUNG
• PERLU SPO: APA SAJA YG HARUS DIHITUNG/ PROSEDUR
• PERAWAT MENGHITUNG SEMUA ITEM YG MEMASUKI BIDANG STERIL
• YANG HARUS DIHITUNG :
– KASA
– FORCEPS, JARUM, RETRAKTOR
– KANTUNG YG DIMASUKAN TUBUH
– DLL
• KAPAN DIHITUNG :
– SEBELUM PROSEDUR ( BASE LINE DATA)
– SEBELUM PENUTUPAN RONGGA TUBUH
– SEBELUM PENUTUPAN LUKA
– WAKTU PENUTUPAN KULIT SETELAH PROSEDUR
– WAKTU TUGAS CIRCULATING NURSE ATAU SCRUB NURSE SELESAI
BAGAIMANA CARA MENGHITUNG
• PERLU SPO YANG JELAS DAN KONSISTEN
• PENGHITUNGAN DIMULAI DI LAPANGAN
PEMBEDAHAN
• KASA TAMBAHAN HARUS DIHITUNG DAN DICATAT
• CHEKLIST YANG SUDAH DICETAK
• SIAPA YG MENGHITUNG :
– HARUS LEBIH 1 ORG PADA SAAT BERSAMAAN
– REKOMENDASI AORN : HARUS DIHITUNG DG SUARA
KERAS DAN JELAS ==> DISAKSIKAN 2 ORANG
– PADA WAKTU MENGHITUNG TIDAK ADA GANGGUAN
PERHATIKAN

• PELATIHAN CARA MENGHITUNG ==> SPO


• KOMUNIKASI EFEKTIF (SELURUH ANGGOTA
TIM)
• X RAY UNTUK PASIEN RESIKO TINGGI
• TEKNOLOGI BARU (ELECTRONIC TAGGING )
Is essential imaging displayed
The Safe Surgery Saves Lives Strategy
(WHO 2009)

1. Promotion of surgical safety as a public


health issue

2. Creation of a checklist to improve the


standards of surgical safety

3. Collection of “Surgical Vital Statistics”


WHO's 10 objectives for Safe Surgery
1. The team will operate on the correct patient at the
correct site.
2. The team will use methods known to prevent harm from
administration of anaesthetics, while protecting the
patient from pain.
3. The team will recognize and effectively prepare for life-
threatening loss of airway or respiratory function.
4. The team will recognize and effectively prepare for risk of
high blood loss.
5. The team will avoid inducing an allergic or adverse drug
reaction for which the patient is known to be at significant
risk.
WHO's 10 objectives for
Safe Surgery (cont.)
6. The team will consistently use methods known to
minimize the risk for surgical site infection.
7. The team will prevent inadvertent retention of
instruments or sponges in surgical wounds.
8. The team will secure and accurately identify all
surgical specimens.
9. The team will effectively communicate and exchange
critical information for the safe conduct of the
operation.
10.Hospitals and public health systems will establish
routine surveillance of surgical capacity, volume and
results.
Reality Check

Currently, hospitals do MOST of the right things, on


MOST patients, MOST of the time.
The Checklist helps us do ALL the
right things, on ALL patients, ALL the time
Advantages
of using a Checklist

 Customizable to local setting and needs


 Supported by evidence
 Evaluated in diverse settings around the world
 Promotes adherence to established safety practices
 Minimal resources required to implement a far-
reaching safety intervention
What is this tool
that addresses the 10 objectives?
57

You might also like