RISK MANAGEMENT TO IMPROVE

PATIENT SAFETY


ARJATY W DAUD
Arjaty Daud/Risk/2014
CURICULUM VITAE
Nama : dr. Arjaty W. Daud, MARS
Alamat : Jl Kemang Timur XIV / 56 Jak Sel
Tmpt / tgl. Lahi : Manado,17 Januari 1969
Status : Menikah
Email : arjaty19@gmail.com,
Hp : 0812 1830 7169

PENDIDIKAN
S-1 Fakultas Kedokteran Universitas Sam Ratulangi - Manado , Lulus 1995
S-2 Fakultas Kesehatan Masyarakat, KARS Universitas Indonesia, Lulus 2005

PELATIHAN / SEMINAR
2011 : Practicum Acreditation JCI Seoul
Patient Safety Course, Singapura
2010 : Safety in Healthcare, Kuala Lumpur
2009 : Hospital Management Asia, Vietnam
Course Risk Management PRMIA Jakarta
2007 : New Perspektif, Conferrence ASHRM, Chicago USA
Certified Profesional Healthcare Risk Management course,
Chicago USA
Risk Management Base Training, Joint Commision Resources (JCR)
Patient Safety Up Date, Joint Commision International (JCI) Singapura
2005: Lead Audior ISO 9001 2000, International Registered Certificated
Auditor (IRCA) 2/28/14 2
PENGALAMAN KERJA
2013 : Konsultan JCI RSU Kanujoso Balikpapan, RSUD Kraton Pekalongan, RSUD Sleman Jogjakarta, RS MMC
2012 : Konsultan JCI RSUP Fatmawati, RSUP Wahidin Sudirohusodo Makasar, RS Medistra
2011 : Konsultan JCI RSCM, Konsultan Manajemen Risiko & Keselamatan Pasien RS Tarakan Kaltim
2010 : Konsultan Manajemen risiko RSUP Fatmawati Jakarta, RS Bieuren, RS Lhoksemawe Aceh
2009 : Konsultan Manajemen risiko & Kes Pasien RS Wahidin Makasar, RS Pelni Jakarta
Konsultan RS Aini, RS Sardjito
2007 : Direktur RS Zahirah
Konsultan Manajemen risiko RS Persahabatan, RS Dharmais
2006 Konsultan Manajemen RS Asri, Konsultan Manajemen RS Medika BSD,
2004 - 2005 : Manajer Operasional Medika Plaza International Clinic
2003 : General Manajer Cempaka Medical Centre
2003 - 2004 : Direktur Operasional RS Sentra Medika
2002 - 2003 : Wakil Direktur Medik & Asist Direktur RS Sentra Medika
2000 - 2001 : Kepala Bagian Humas RS MMC
1999 - 2000 : Kepala Bagian Rehabilitasi Medik RS MMC
1999 : Asisten Konsultan WHO Umbrella Project Depkes
1996 -1999 : Kepala Puskesmas Sindang Barang Kabupaten Cianjur

ORGANISASI
2007 2012 : Ketua Bidang IV (Pelaporan Insiden) KKP RS PERSI , Sterring Committe KKP RS
2005 - Saat ini:Ketua Institut Manajemen Risiko Klinis (IMRK) / ICRMI
Member of ASQ (American Quality Society),
Member of Profesional Risk Management International Association

2/28/14 Arjaty Daud/Risk/2014 3
PRIMUM, NON
NOCERE
FIRST, DO NO
HARM
!"##$%&'()*+* ()-)(
./012334 5%6
IOM (2000):
44.000 98.000
Adv event
Estimasi biaya:
$17 - $50 milyar

Meninggal krn :
KLL :
43,458
Cancer :
42,297
AIDS :
16,516

Arjaty/IMRK/2008
IOM : To Err is Human
Building a Safer Health System
Redesign system
(Improve)
REDESAIN SISTEM AGAR ORANG MUDAH UNTUK BERBUAT BENAR &
SULIT UNTUK BERBUAT SALAH
Leassons
Learned
Investigation &
Analysis
Reporting
Fear of
Blame
Risk vs. Medical Error
Risks
Medical
Errors
Potential Failure Actual Failure
What is going wrong
With this process?
What could go wrong
With this process?
2/28/14 Arjaty Daud/Risk/2014 6
Full range of
Near Miss events,
Response


On-going data
collection

Examples
Majority of
medication
errors
Actual SE
Adverse events
"Important single events"


Conduct RCA
Not subject to SE
definition
Evaluate process
at triennial survey
Significant
misadministration
-- patient survives


SE
Policy
"reviewable"

JCI can review RCA
Add to SE Database

Patient death from medication
misadministration

High Risk
Processes
2/28/14 Arjaty Daud/Risk/2014 7
Medical Error
Procces of care error
Pasien
tidak terpapar
Pasien
terpapar
Near Miss
Adverse Event
Kesalahan proses yg dpt
dicegah :
Error in planning
Error in Execution
(KTD=Kejadian Tdk Diharapkan)
- ERROR, diket, dibatalkan (prevention)


(KNC=Kejadian NYARIS CIDERA)
No Harm Event
Pasien
cidera
Tidak
cidera
(KTC=Kejadian TIDAK CIDERA)
- Dpt obat c.i., tdk timbul (chance)
- Dpt obat c.i., diket, beri anti-nya
(mitigation)
Dpt dicegah

Krn berbuat : commission
Krn tidak berbuat : omission
Proses of Care
Non Error
significant
potential for harm
situation
Pasien
terpapar
reportable
circumstance
Adverse Event

-TIDAK Dpt dicegah

(KTD=Kejadian Tdk Diharapkan)
Pasien
cidera
Tidak
cidera
(KPC=Kondisi Potensi Cedera)
Arjaty Daud/Risk/2014
JENIIS INSIDEN YG HARUS DILAPORKAN
1. KEJADIAN SENTINEL
2. KEJADIAN TIDAK DIHARAPKAN (KTD)
Insiden yang mengakibatkan cedera pada pasien
3. KEJADIAN TIDAK CEDERA (KTC)
Insiden yang sudah terpapar kepada pasien tapi tidak
menimbulkan cedera
4. KEJADIAN NYARIS CEDERA (KNC)
Insiden yang belum terpapar kepada pasien
KONDISI POTENSIAL RISIKO / CEDERA YANG HARUS DILAPORKAN
KONDISI POTENSIAL CEDERA (KPC)

Kondisi yang berpotensial menimbulkan cedera tapi belum terjadi insiden
2/28/14 10
Arjaty/IMRK/2008
Paul Barach, MD, MPH, Univ of Miami Medical School
Passenger
Pilot
Plane
KTP = Tiket ?
Boarding pass
Check in
Bagage
Boarding Pre take off
Hitung / check
Sehat ?
screening
screening
check
check check
check
check
Arjaty/IMRK/2008








Safe
Practice consistent with
Current medical knowledge
Customization
Safety :
reduce risk
Best practice,
EBM
Meeting
customer
value &
expectation
s
DOMAINS OF QUALITY
Arjaty/IMRK/2008
Process of care


Health
Outcome
Input Health
Services
Activities
How ?
Why ?
Patient
Impact
Who ?
PERSON
APPROACH :
SYSTEM
APPROACH :
STOP
!
Focuses on
the errors & violations Of
individuals
Traces the causal factors
back into the system As a whole
Bukan berarti semua orang dapat melakukan
kecerobohan
Setiap orang harus waspada dan
bertanggung jawab terhdp
apa yg dikerjakan
MEDICAL ERROR
Arjaty/IMRK/2010
Error in
Execution
Slips
15
16
Similar Vials:
Cefazolin and
Vecuronium
Similar Vials: Atropine &
Phenylephrine
17
Medlcauon CarL urawer
Arjaty/IMRK/2008
Arjaty/IMRK/2008
Pau-hau .....
SLuACuM & 8CCuLAx
Arjaty/IMRK/2008
oor handwrlung
Lotrison or Lotrimin ?
Coumadin or Kemadrin ?
Doxorubicin or Daunorubicin ? Pentobarbital or Phenobarbital ?
Arjaty/IMRK/2008
LCCk ALlkL SCunu ALlkL
Arjaty/IMRK/2008
!"#$"# $&#"'"# ()#$'"*"#
Arjaty/IMRK/2008
Arjaty/IMRK/2008
Arjaty/IMRK/2008
Lxamples





Intended dose of 4 units in patient history
interpreted as 44 units. U should be written out
as unit.
Arjaty/IMRK/2008
Lxamples

Iniended dose of ".( mg" inieipieied as ( mg
fiom medicaiion oidei. Slould be wiiiien as "o.(
mg."
Arjaty/IMRK/2008
Lxamples
"7897:9: ;9<=>>97:?8@=7 =A BC9DD 8E?7 F1G H?D
@789;I;989: ?D /J BKG DE=LC: M9 H;@8897 =L8 ?D BC9DD
8E?7JG
Arjaty/IMRK/2008
&+,-. */01-232.4 52 6/780/ 9/7,0:;2- /<<2<
=>?@ 2< A>?= B AA=6
! Sejal lapoian IOM ialun iqqq ,
penggunaan CPOE ielal membaniu
meiedulsi medicaiion eiiois.
#979C@8@?7 >97L7NLOO?7 %#$)
>9;9:LOD@ 9;;=; D9M9D?; 44PJ
! Idealnya, pemesanan ini diiniegiasilan
dengan infoimasi lain daii pasien spi
pemeiilsaan laboiaioiium.
Arjaty/IMRK/2008
Wayne meninggal dunia di QUeens Medical Center,
Nottingham, Inggris, tepat j 08.00 setelah diberi Vincristine
yang harusnya IV, tapi diberikan ke tulang belakang. Yang
harusnya disuntikkan di tulang belakang adalah Cytosine.

Dr Feda M dikenai hukuman 8 bulan penjara setelah
mengakui secara tidak sengaja membunuh pasien leukemia
yang usianya sangat muda.



Risk vs. Medical Error
Risks
Medical
Errors
Potential Failure Actual Failure
What is going wrong
With this process?
What could go wrong
With this process?
2/28/14 Arjaty Daud/Risk/2014 30
Risiko di Rumah Sakit

! &"*"Q$ QR"-"* S %C@7@<?C &@DO T
*9>L? @DL U?7V :?I?8 M9;:?>I?O 89;E?:?I
I97<?I?@?7 I9C?U?7?7 I?D@97 U?7V M9;>L8L
8@7VV@W ?>?7 :?7 9A9O8@AJ
! &"*"Q$ -$-QR"-"*S %=;I=;?89 &@DO :
*9>L? @DDL U?7V :?I?8 M9;:?>I?O 89;E?:?I
89;<?I?@7U? 8LV?D I=O=O :?7 O9H?N@M?7
ELOL> :?;@ ;L>?E D?O@8 D9M?V?@ O=;I=;?D@J
31
9"#"!@9@# 6)()'? 6&9"C ("')*
32
Kegiatan berupa identifikasi dan evaluasi untuk
mengurangi risiko cedera dan kerugian pada pasien,
karyawan rumah sakit, pengunjung dan organisasinya
sendiri (The Joint Commission on Accreditation of Healthcare Organizations / JCAHO).
Kegiatan meminimalkan bahaya terhadap pasien,
kegiatan untuk menciptakan lingkungan yang
aman bagi karyawan, pasien dan pengunjung (ASHRM)
Hosp
Risk
Mgt
Patient care
Related
Risks
Medical Staff
Related Risks
Employee
Related
Risks
Property
Related
Risks
Other
Risks
Roberta Caroll, editor : Risk Management Handbook for Health Care
Organizations, 4
th
edition, Jossey Bass, 2004
Financial
Risks
Patient
Safety
Health &
Safety
Clinical

Employment
MANAJEMEN RESIKO TERINTEGRSI
O
R
G
A
N
I
S
A
S
I

R
S

Lessons
learned
Identify and Reduce
Unanticipated Adverse Events
! Leaders adopt a framework that:
! Risk identification & prioritization,
! Risk reporting and management
! Investigation of adverse events
! Management of related claims
! Conducts and documents a pro-
active risk reduction annually
! Take action to redesign high-risk
processes based on analysis
Risk
Identification
Risk
Assessment
Risk
Reduction
Risk Management
Framework
2/28/14 Arjaty Daud/Risk/2014 35
Risk Management Steps
1. Understand Risk
2. Identify High Risk Processes (Get input from
stakeholders)
3. Conduct a Risk Assessment
4. Conduct Proactive Risk Analysis
5. Develop Mitigating Strategies
6. Develop Contingency Plans
7. Implement Strategies and Plans
8. Reassess Risks
2/28/14 Arjaty Daud/Risk/2014 36
Step 1: Establish Risk Management Program
! Examples:
! Sub-committee of the overall QIPS program
! A risk management coordinator integrated into
the QIPS program
! Need to ensure organization-wide,
interdisciplinary representation.
2/28/14 Arjaty Daud/Risk/2014 37
Step 2: Identify Organization-Wide
High Risks Processes
! Sources of information:
! Patient complaints
! Incident reports (OVAR)
! Medication error reports (MMU.7.1)
! Adverse event (medical error) monitoring (QPS.6-8)
! Environmental assessments (FMS.3.1)
! Ifection control assessments (PCI.5)
! Insurance or legal claims
! Safety walks or tracers
2/28/14 Arjaty Daud/Risk/2014 38
Arjaty/IMRK/2008
)D@#*)E)'"() 6)()'?
! Incident reporting (Laporan Insiden)
! Case Report
! Complaint
! Claim data
! Clinical care review
! Audit Medis
! Occurrence Screening /
Medical Record Review
! Survey / Self Assesment
Reaktif
Proaktif
Categories of High Risk Processes
Types of infections, including organisms of
epidemiological significance
At-risk patient or resident populations
Supplies and equipment risks
Emergency preparedness
Environmental issues
Geographic considerations
Community considerations
Identify specific risk process
In each category
2/28/14 Arjaty Daud/Risk/2014 40
Is This a High Risk Process?
2/28/14 Arjaty Daud/Risk/2014 41
Step 3: Prepare a Prioritized List of
High Risk Processes
! Have leaders use prioritization criteria to
prepare list
! List should reflect high risk process
processes for which failure has or will result
in harm to patients, staff, visitors, or
contract workers
You need standardized numerical values or criteria
to assess risks!!!
2/28/14 Arjaty Daud/Risk/2014 42
Risk Ranking and Prioritization Methods
! List each high risk process
! For each high risk process, assign a score
(H,M,L) for each prioritization criteria
! Create a ranked prioritize list of high risk
processes
2/28/14 Arjaty Daud/Risk/2014 43
Risk Ranking and Prioritization Criteria
! Usual prioritization criteria are:
! Probability or likelihood of occurrence
! Risk of harm (criticality) or impact
! System capacity or preparedness
2/28/14 Arjaty Daud/Risk/2014 44
Risk Ranking and Prioritization Criteria
! Sometimes criteria given numerical weight of
1-5 or 1-10 (refer to prioritization tool)
! Each criteria scored as low, medium, or high
which is 1,3,5 or 1,5,9, or scored from 1-10
Assigning numbers to ordinal scales
2/28/14 Arjaty Daud/Risk/2014 45
Prioritization Tool
Criteria Score
2/28/14 Arjaty Daud/Risk/2014 46
Step 4: Use Proactive Risk Reduction
Tool for Analysis and Prioritization
! Tools:
! Failure Mode Effect Analysis- FMEA
! Healthcare Failure Mode Effect Analysis
HFMEA
! Hazard Vulnerability Analysis - HVA
! Apply analysis tool to a list of high risk
processes, starting with the highest priority
2/28/14 Arjaty Daud/Risk/2014 47
Step 5: Develop and Implement
Solutions
! It is the job of management not only to assess
risk, but also to identify effective courses of
action to eliminate or mitigate that risk
! This commitment to implementing risk reduction
methods transforms risk assessment into risk
management
! Use a FMEA/RCA method to identify root
causes and potential solutions
2/28/14 Arjaty Daud/Risk/2014 48
CONCLUSION
Improved collaboration between risk management, patient safety
and quality improvement will contribute to an organizations
success in enhancing Patient safety Program and minimizing
patient harm.
2/28/14 Arjaty Daud/Risk/2014 49
QUALITY
MANAGE
R
RISK
MANAGER
2/28/14 Arjaty Daud/Risk/2014 50