Bayu Wahyudi

RIWAYAT HIDUP
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NAMA
Pangkat / Gol
Tempat Tgl Lahir
Jabatan
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Dr. H.BAYU WAHYUDI, MPHM, SpOG
Pembina Utama Madya / IV D
Jakarta, 1 Maret 1962
Direktur utama RSUP Dr.HASAN SADIKIN BANDUNG
1. FK Unsri ( Dokter Umum)
2. AIHD Mahidol Univ Bangkok (MPHM) Fellows WHO
3. FK Unsri ( Spesialis Obgin)
4. On Going : Doktoral (Candidate) FK Unpad
MHKes ( Unika Soegiya Pranata)
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Pekerjaan : 1. Ka Puskesmas transimigras Air Sugihan Jalur 27 & Jalur 25 OKI SumSel
2. Pimp Proyek PKLP Kanwil Prov.Sumsel
3. Dokter Fungsional Obgin RSUD Liwa Lampung Barat
4. Koord Executive UNFPA (Kanwil Prop. Sumsel )
5. Direktur RS Kusta dr.Rivai Abdulah Palembang (RSSK)
6. Direktur Medik & Keperawatan RSUP dr.M.Hoesin (RSMH) Palembang
7. Direktur Utama RSUP dr.Moh.Hoesin (RSMH) Palembang
8. Direktur Utama RSUP dr. Hasan Sadikin (RSHS) Bandung
CONTRIBUTION OF PHARMACY EDUCATION
IN PROMOTING PATIENT SAFETY AT RSHS
The 3rd Asia Pacific Pharmacy Education Workshop
School of Pharmacy ITB Bandung, 20 t h November 2012
Bayu Wahyudi
(President Director RSUP Dr.Hasan Sadikin Bandung)
Introduction
• Reports from the IOM (Institute of Medicine) 1999:
- At least 44,000 patients died in hospital within a year due
to medical errors that could have been prevented.
- This quantity exceeds deaths due to traffic accidents,
breast cancer and AIDS.
• In pharmaceutical research Bates (JAMA, 1995) shows that
the highest levels of medication errors:
- Ordering stage (49%)
- Management administration (26%)
- Pharmacy management (14% )
- Transcribing (11%).
SSM/SH
• Reports National Patient Safety Incident
(Persatuan Rumah Sakit Indonesia / IMHA
Congress, Sep 2007);
Errors in drug administration was ranked first
(24.8%) of the 10 major incidents.
• Research at RSHS / HSGH (2002) ;
Potential error in pharmacy process: 0.26%
SSM/SH
STATUS HSGH
Government-owned Hospital
Under and directly responsible to the Directorate General of
Heatlh Care, Ministry of Health
Class A Hospital
Teaching Hospital
Top Referral Hospital for West Java Province
National Center of Excellence for Nuclear Medicine
The only Educational Center for Nuclear Medicine Specialist in
Indonesia
Iso 9001- 2008
RSUP Dr.Hasan Sadikin Bandung
Jalan Pasteur No. 38 Bandung telephone.62-022-2034953/57 Fax.62-022-2032216
MISSION
VISION
To Be a World Class Indonesian Hospital
Excelling In Health Services, Education &
Research
Menjadi Rumah sakit Indonesia Kelas
Dunia yang Unggul dalam Pelayanan,
Pendidikan dan Penelitian
To Provide Comprehensive and Excellent
Services Integrated with Education and
Research
Melaksanakan Pelayanan Kesehatan
Paripurna dan Prima yang Terintegrasi
dengan Pendidikan dan Penelitian
MOTTO
VALLUE
Professional, Respect, Integrity,
Humanistic, Realtives
Profesional Respek Integritas Manusiawi
Amanah
Your Health is Our Priority
Kesehatan Anda Menjadi Prioritas Kami
RSUP Dr.Hasan Sadikin Bandung
Jalan Pasteur No. 38 Bandung telephone.62-022-2034953/57 Fax.62-022-2032216
OBJECTIVES
 To provide standardized integrated-health services
focusing on the customer satisfaction which have
regional competitive advantage.
 To materialize HSGH as a model of teaching
hospital in Indonesia.
 To materialize HSGH as a research based hospital
 To increase the hospital cost recovery as the effort
to be a self financing hospital
Dr.Hasan Sadikin General Hospital
Jalan Pasteur No. 38 Bandung West Java Indonesia Phone.62-022-2034953/57 Fax.62-022-2032216
STAFF STRENGTH
February, 2012
Strategic Staff
447
(14%)
Security
22
(1%)
Administration
447
(14%)
Dental
Specialist
33
(1%)
General
Dentist
15
(1%)
General Physician
42
(1%)
Medical Specialist;
365; 11%
Medical Specialist
General Physician
Dental Specialist
General Dentist
Nurse
Widwife
Paramedics
Non
Health
Functional
Staff
18
(1%)
Paramedics
574
Widwife
(18%)
94
(3%)
Non Health
Functional Staff
Administration
Strategic Staff
Nurse
1130
(35%)
Total: 3.187 staff
OUT PATIENT DEPARTMENT
• 20 specialty clinics and 16 Excellent clinics specialist ,
for 127 subspecialties for regular patients located in
the Out-patient Department ( 2.000 – 3.000 patient/
day)
OPD 2
28 specialist clinics for executive class located in the
Anggrek Building
Number of OPD Visit
Years 2001 to 2011
700.000
600.000
580.535
527.771
557.346
510.097
500.000
400.000
551.321
Registration Counter
403.216
367.798
344.542
300.000
332.459
298.160
304.333
200.000
100.000
20
11
20
10
20
09
20
08
20
07
20
06
20
05
20
04
20
03
20
02
20
01
0
Dr.Hasan Sadikin General Hospital
Jalan Pasteur No. 38 Bandung West Java Indonesia Phone.62-022-2034953/57 Fax.62-022-2032216
SPECIALIST CLINIC
Laboratory
Waiting Room
Level 2
Information Service
Pharmacy
Dr.Hasan Sadikin General Hospital
Jalan Pasteur No. 38 Bandung West Java Indonesia Phone.62-022-2034953/57 Fax.62-022-2032216
Radiology
Waiting Room
Level 1
In Patient Department
BED CAPACITY BY CLASSES
Dr. HASAN SADIKIN GENERAL HOSPITAL
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CLASSES
NUMBER
%
1.
VIP
121
11,00
2.
CLASS I
107
9,73
3.
CLASS II
137
12,45
4.
CLASS III (POOR PATIENT)
650
59,09
5.
Intensive (GICU, ICCU,
PICU,NICU)
35
3,18
6.
High Care Unit + Radio
Therapy + Nucl.
Nucl. Med +
Isolation Ward
50
4,54
Total
1.100
100,00
Medical Wards
VIP Wards
Dr.Hasan Sadikin General Hospital
Jalan Pasteur No. 38 Bandung West Java Indonesia Phone.62-022-2034953/57 Fax.62-022-2032216
Ingat UU 44/2009
Rumah Sakit sebagai suatu sistem, dengan
Manajemen sebagai representatif atau
penanggungjawab
Pasal 46
• Rumah Sakit bertanggung jawab secara
hukum terhadap semua kerugian yang
ditimbulkan atas kelalaian yang dilakukan
oleh tenaga kesehatan di Rumah Sakit.
RSUP Dr.Hasan Sadikin Bandung
Jalan Pasteur No. 38 Bandung telephone.62-022-2034953/57 Fax.62-022-2032216
Penjelasan ps 36 UU 44/2009
Tata kelola rumah sakit yang baik adalah
penerapan fungsi-fungsi manajemen rumah sakit
yang berdasarkan prinsip-prinsip transparansi,
akuntabilitas, independensi dan responsibilitas,
kesetaraan dan kewajaran.
Tata kelola klinis yang baik adalah penerapan
fungsi manajemen klinis yang meliputi
kepemimpinan klinik, audit klinis, data
klinis, risiko klinis berbasis bukti,
peningkatan kinerja, pengelolaan keluhan,
mekanisme monitor hasil pelayanan,
pengembangan profesional, dan akreditasi
rumah sakit.
RSUP Dr.Hasan Sadikin Bandung
Jalan Pasteur No. 38 Bandung telephone.62-022-2034953/57 Fax.62-022-2032216
RSHS BANDUNG
ONE TEAM, ONE VISION, ONE GOAL
Harus dapat hidup , Harus dpt m’layani Masyarakat
Harus Profesional, Harus mandiri
Harus dapat bersaing ,Harus dapat berkembang
WORLD CLASS HOSPITAL (JCI) 2012-13
HEALTH TOURISM
STANDAR PELAYANAN
PADAT KARYA,
- PADAT SDM,
- PADAT TEKNOLOGI,
- PADAT MODAL
- PADAT MASALAH
PATIENT SAFETY
PATIENT SATISFACTION
WTP
RS Pendd
TOGETHERNESS
BLU
PENINGKATAN SDM
INFRA STRUKTUR
SARANA
PRASARANA
SABILULUNGAN
SAUYUNAN,
SAPIHANEAN
SABANDA
SARIKSA
KEMKES + KEMDIKNAS+ PEMDA + NGO + MASYARAKAT
RISET
PENDIDIKAN
•Peningkatan produktivas
•Mutu pelayanan RS (PATIENT SATISFACTION)
•Keselamatan pasien (PATIENT SAFETY)
•Hukum + Kesejahteraan
menjadi RSI kelas dunia
melalui akred internasional JCI
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PERCEPATAN REFORMASI BIROKRASI DLM RANGKA
MENINGKATKAN DAYA SAING RSHS
BERGESERNYA POLA MANAJEMEN RUMAH SAKIT
UPAYA
DULU
SEKARANG
KESELAMATAN PASIEN
(PATIENT SAFETY)
MELAYANI PASIEN
PROFIT, UNTUK HIDUP DAN
TUMBUH BERKEMBANG
MELAKSANAKAN KEGIATAN
EFFISIEN , INTERPREUNER
KEPUASAN PASIEN
(PATIENT SATISFACTION)
MINTA DAN HABISKAN
ANGGARAN
ATURAN BIROKRASI
MEMBELENGGU
KELELUASAAN MENGATUR
(BERBASIS KINERJA) FLEKSIBEL
JCI
JOINT COMMISSION INTERNATIONAL
7 K = (KOTOR, KUMEL, KODOL, KUDEL
KUMUH, KESET, KLELERAN, KEJAM)
PELAYANAN OPTIMAL
(EXCELLENCE SERVICE QUALITY)
KESEJAHTERAAN
JENIS KESALAHAN (TYPE of ERRORS)
DIAGNOSTIC ERROR:
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Kesalahan atau keterlambatan membuat diagnosis.
Tidak menggunakan tes yang diindikasikan.
Menggunakan tes yang sudah ketinggalan zaman.
Tidak bertindak terhadap hasil atau monitoring tes.
TREATMENT ERROR:
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Kesalahan dalam proses kerja, prosedur atau tes.
Kesalahan memberikan terapi.
Kesalahan dosis atau cara memberikan obat.
Keterlambatan (yang dapat dicegah) utk memberikan
terapi atau merespon hasil abnormal suatu tes.
 Melakukan perawatan tak benar /tak ada indikasi
KESALAHAN PENCEGAHAN (PREVENTIVE ERROR):
 Tidak menyediakan prophylactic treatment.
 Tidak cukup melakukan monitoring atau follow-up
terhadap terapi / tindakan yang telah diberikan.
KESALAHAN LAIN
 Kegagalan komunikasi.
 Kegagalan peralatan (equipment failure).
 Kegagalan dari sistem-sistem lainnya.
Leape et al, Quality Review Bulletin, 1993
Situation
SSM/SH
Defini
Definition
tion
(menurut US Pharmacopoeia)
:
“any preventable event that may cause or lead
to inappropriate medication use or patient harm
while the medication is in the control of health
care professional, patient, or consumer. Such
events may be related to professional practice,
health care products, procedures, and systems,
including prescrebing; order communication;
product labeling, packaging, and nomenclature;
compounding; dispensing; distribution;
administration; education; monitoring; and use”
SSM/SH
SAFETY IS A CULTURE:
SA F E T Y C U LT U R E
B L A M E F R E E C U LT U R E
R
R E P O R T I N G C U LT U R E
L EA R N I N G C U LT U R E
EDUCATION
SSM/SH
Situation
SSM/SH
PREVENTION IS
STILL THE BEST DEFENS
AGAINST THE ACCUSATION OF
MALPRACTICE.
(Morris, Moritz)
DRUG PROCESS TO THE PATIENT
Selection &
Procurement
Monitoring
Storage
Administration
Ordering and
Transcribing
Preparing and
Dispensing
MANAGING MEDICATION ERROR
• Necessary corrective and supportive therapy
• Documented and reported
• Gathering fact and investigation
(for significant errors)
• Review and prevented way
• Information about medication error, educational
tool for staf, disciplinary action
• Supervisor
• Reported to national monitoring program
METHODS USED TO MINIMIZE MEDICATION ERROR
Forcing functions and constrains
Most
Effective
Automation and computerizations
Standardization and protocols
Checklists and double check Systems
Rules and policies
Least
Effective
Education/information
Be more careful, be vigilant
QUALITY ASSURANCE: JCI ACCREDITATION
SSM/SH
Standar Akreditasi JCI
Patient
Centered Standards
Health care organization
management standards
1. International Patient Safety
Goals (IPSG)
2. Access to Care and Continuity
of care (ACC)
3. Patient and Family Rights (PFR)
4. Assessment of Patients (AOP)
5. Care of Patients (COP)
6. Anesthesia and Surgical Care
(ASC)
7. Medication Management and
Use (MMU)
8. Patient and Family Education
(PFE)
1. Quality improvement and
Patient Safety (QPS)
2. Prevention and Control of
Infections (PCI)
3. Governance, Leadership,
and Direction (GLD)
4. Facility Management and
Safety (FMS)
5. Staff Qualifications and
Education (SQE)
6. Management of
Communication and
Information (MCI)
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JCI-standar akreditasi internasional
Standar 14 buah
• Standar berfokus pasien
8 buah
• Standar berfokus
manajemen 6 buah
Elemen :1214
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IPSG :23
ACC : 104
AOP : 184
COP : 74
ASC : 51
MMU : 82
PFE : 27
QPS; 88
PCI : 83
GLD : 98
FMS : 92
SQE : 99
PFE : 27
MCI : 109
ADVERSE EVENT
STANDAR LAYANAN
TIDAK TERPENUHI
STANDAR LAYANAN
TERPENUHI
DIRECT CAUSATION
RISIKO
MEDIK
UNFORESEEN
RISK (tdk diduga)
BUKAN
MAL PRAKTEK
DAMAGES
FORESEEN
RISK (diduga)
Melakukan
ANTISIPASI
Tanpa
ANTISIPASI
MALPRAKTEK
DAMAGES
DIRECT CAUSATION
SISTEM PELAPORAN KEJADIAN (INCIDENT
REPORT SYSTEM) di Rumah Sakit ( RSHS )
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Untuk Iaporan dan evaluasi
Sebagian dari Critical Risk Management
Untuk perkecil risiko utk pasen dan petugas
Untuk kepentingan yang berhubungan dengan
aspek hukum
Kegiatan Keselamatan Pasen Rumah Sakit
• 7 Langkah Keselamatan pasen RS
• Membuat Pedoman Keselamatan Pasen RS sesuai
akreditasi
• Pertemuan rutin Pengayaan pada anggota
Keselamatan Pasen RS
• Sosialisasi kegiatan Program Keselamatan pasen RS
• Laporan Insiden Keselamatan Pasien
• (Membuat SMS Hotline Patient Safety RSHS :
081220050547)
STORAGE
SSM/SH
HIGH ALERT MEDICATION
Look alike
Sound alike (LASA)
High Concentrate Solution
SSM/SH
MEDICATION ORDER REVIEW
SSM/SH
DRUG INFORMATION
MEDIA OF INFORMATION
Patient and Family Education
SSM/SH
DRUG COUNSELING
To catch:
1. Right Patient
2. Right Indication
3. Right Medicine
4. Right Dose
5. Right Route of Administration
6. Right Time
7. Right Information
Patient compliance
Goal of theraphy
SSM/SH
Quality of Life
THERAPY DRUG MONITORING
To Prevent Drug Related Problems (DRP’s)
SSM/SH
CLINICAL PHARMACY ACTIVITY
Dosis ganda
Dosis tidak jelas
Dosis tidak lazim
17,7
Dosis tidak sama
Duplikasi generik
DUPLICATION OF GENERIC NAME
Duplikasi Terapi
Lama pemberian tidak tepat
Obat tanpa indikasi
24,1
OVER DOSAGE
DUPLICATION OF DRUG THERAPHY
Order obat tidak jelas: salah obat
Over Dosis
30,4
Polifarmasi
Salah signa
SSM/SH
Sub Dosis
Manfaat penerapan
Sistim Keselamatan pasien RS
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6.
7.
Budaya safety meningkat & berkembang
Komunikasi dengan pasen berkembang
KTD menurun, dan peta KTD selalu ada dan terkini
Risiko klinis menurun
Keluhan dan ligitasi berkurang
Mutu pelayanan meningkat
Citra RS dan pelayanan meningkat, diikuti
kepercayaan diri meningkat
KESIMPULAN
IMPROVE THE SAFETY - GOOD OUT COME
Lakukan Analysis
– Man
– Machine
– Materials
– Method
– Money
– Marketing
: dokter, perawat, nonmedis
: alat terawat, dikalibrasi,
SPO cara penggunaan, merk.
: BMHP/obat, labeling, barr code,
standar warna/ gambar.
: informed consent, SOP, report,
audit , monitor.
: bayar, asuransi, subsidi
: Promosi, Pencegahan
PRINSIP-PRINSIP MERANCANG SISTEM YANG
AMAN (SAFETY SYSTEM ) di Rumah Sakit
1. Provide Leadership.
2. Ingat ada keterbatasan manusia dalam
membuat desain.
3. Pikirkan bagaimana tim akan bekerja efektif .
4. Antisipasi hal-hal yang tidak dapat diduga.
5. Mempelajari keadaan lingkungan sekitar.
7 Langkah menuju Keselamatan Pasen RS
1.
2.
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6.
Bangun kesadaran akan nilai keselamatan pasen
Pimpin dan dukung staf anda
Integrasikan aktivitas pengelolaan risiko
Kembangkan sistim pelaporan
Libatkan dan berkomunikasi dengan pasen
Belajar dan berbagi pengalaman tentang
keselamatan pasen
7. Cegah cedera melalui implementasi keselamatan
pasen
9 Langkah Solusi Keselamatan Pasen RS
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Perhatikan nama obat, rupa & ucapan mirip
Pastikan Identifikasi Pasen
Komunikasi secara benar saat serah terima/operan pasen
Pastikan yang benar pada tubuh sisi yang benar
Kendalikan cairan elektrolit pekat
Pastikan akurasi pemberian obat pada pengalihan
pelayanan
Hindari salah kateter dan salah sambung slang
Gunakan injeksi sekali pakai
Tingkatkan kebersihan tangan untuk mencegah infeksi
nosokomial
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SAFETY AND SATISFACTION FOR ALL …!!
COMING
TOGETHER,
IS A BEGINNING
WORKING
TOGETHER,
IS A PROGRESS
KEEPING
TOGETHER,
IS A SUCCESS
RSUP Dr.Hasan Sadikin Bandung
Jalan Pasteur No. 38 Bandung telephone.62-022-2034953/57 Fax.62-022-2032216
HATUR
NUHUN