1 CURRICULUM VITAE CURRICULUM VITAE DATA PRIBADI DATA PRIBADI Nama : Nama : dr.ADIB ABDULLAH YAHYA,MARS dr.ADIB ABDULLAH YAHYA,MARS Pangkat : Brigjen TNI (Purn) Pangkat : Brigjen TNI (Purn) Tempat/tanggal lahir : Magelang,16 Februari 1949 Tempat/tanggal lahir : Magelang,16 Februari 1949 Jabatan : Jabatan : President Asian Hospital Federation (AHF) President Asian Hospital Federation (AHF) Agama : Islam Agama : Islam ALAMAT : Jl. Punai H-24,Kel.Tengah,Jakarta Timur – 13540 ALAMAT : Jl. Punai H-24,Kel.Tengah,Jakarta Timur – 13540 Telp : (021)8404580 Telp : (021)8404580 Fax : (021) 8408047 Fax : (021) 8408047 HP : HP : 08161803497 08161803497 E-MAIL : E-MAIL : [email protected][email protected]PENDIDIKAN UMUM PENDIDIKAN UMUM SMA Negeri Magelang 1966 SMA Negeri Magelang 1966 S1 : Fakultas Kedokteran Universitas Gajah Mada (UGM), S1 : Fakultas Kedokteran Universitas Gajah Mada (UGM), Yogyakarta, 1973 Yogyakarta, 1973 S2 : Fakultas Kesehatan Masyarakat, Universitas Indonesia (UI), Jakarta, S2 : Fakultas Kesehatan Masyarakat, Universitas Indonesia (UI), Jakarta, Program Kajian Administrasi Rumah Sakit ( KARS ) Program Kajian Administrasi Rumah Sakit ( KARS ) PENDIDIKAN MILITER PENDIDIKAN MILITER Sekolah Staf dan Komando TNI Angkatan Darat (SESKOAD), 1987/1988 Sekolah Staf dan Komando TNI Angkatan Darat (SESKOAD), 1987/1988 PELATIHAN PELATIHAN Combined Humanitarian Assistance Response Training, oleh Singapore Armed Forces (SAF), Combined Humanitarian Assistance Response Training, oleh Singapore Armed Forces (SAF), Singapura, 2000 Singapura, 2000 Health as a Bridge for Peace Workshop, oleh World Health Organization (WHO), Yogyakarta, 2000 Health as a Bridge for Peace Workshop, oleh World Health Organization (WHO), Yogyakarta, 2000
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03. Patient Safety is a Key Component of Risk Management - Dr. Adib a Yahya
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CURRICULUM VITAECURRICULUM VITAE DATA PRIBADIDATA PRIBADI
Nama : Nama : dr.ADIB ABDULLAH YAHYA,MARSdr.ADIB ABDULLAH YAHYA,MARSPangkat : Brigjen TNI (Purn)Pangkat : Brigjen TNI (Purn)Tempat/tanggal lahir : Magelang,16 Februari 1949Tempat/tanggal lahir : Magelang,16 Februari 1949
Jabatan : Jabatan : President Asian Hospital Federation (AHF)President Asian Hospital Federation (AHF) Agama : IslamAgama : IslamALAMAT : Jl. Punai H-24,Kel.Tengah,Jakarta Timur – 13540ALAMAT : Jl. Punai H-24,Kel.Tengah,Jakarta Timur – 13540
SMA Negeri Magelang 1966SMA Negeri Magelang 1966S1 : Fakultas Kedokteran Universitas Gajah Mada (UGM), S1 : Fakultas Kedokteran Universitas Gajah Mada (UGM),
Yogyakarta, 1973Yogyakarta, 1973S2 : Fakultas Kesehatan Masyarakat, Universitas Indonesia (UI), Jakarta, S2 : Fakultas Kesehatan Masyarakat, Universitas Indonesia (UI), Jakarta,
Program Kajian Administrasi Rumah Sakit ( KARS )Program Kajian Administrasi Rumah Sakit ( KARS )
PENDIDIKAN MILITERPENDIDIKAN MILITER
Sekolah Staf dan Komando TNI Angkatan Darat (SESKOAD), 1987/1988Sekolah Staf dan Komando TNI Angkatan Darat (SESKOAD), 1987/1988
PELATIHANPELATIHAN
Combined Humanitarian Assistance Response Training, oleh Singapore Armed Forces (SAF), Singapura, 2000Combined Humanitarian Assistance Response Training, oleh Singapore Armed Forces (SAF), Singapura, 2000Health as a Bridge for Peace Workshop, oleh World Health Organization (WHO), Yogyakarta, 2000 Health as a Bridge for Peace Workshop, oleh World Health Organization (WHO), Yogyakarta, 2000
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PENGALAMAN JABATANPENGALAMAN JABATANKomandan Detasemen Kesehatan Pasukan Pengamanan Presiden (DanDenkes Komandan Detasemen Kesehatan Pasukan Pengamanan Presiden (DanDenkes Paspampres), 1987-1991Paspampres), 1987-1991Kepala Rumah Sakit “Muhammad Ridwan Meuraksa”, Jakarta, 1992Kepala Rumah Sakit “Muhammad Ridwan Meuraksa”, Jakarta, 1992Kepala Kesehatan Daerah Militer (Kakesdam) Jaya, Jakarta, 1993Kepala Kesehatan Daerah Militer (Kakesdam) Jaya, Jakarta, 1993Komandan Pusat Pendidikan Kesehatan TNI – AD,1995 – 1999Komandan Pusat Pendidikan Kesehatan TNI – AD,1995 – 1999Wakil Kepala Pusat Kesehatan TNI, 1999 – 2000Wakil Kepala Pusat Kesehatan TNI, 1999 – 2000Kepala RSPAD Gatot Soebroto, 2000 – 2002Kepala RSPAD Gatot Soebroto, 2000 – 2002Dekan Fakultas Kedokteran UPN, Jakarta, 2000 – 2002Dekan Fakultas Kedokteran UPN, Jakarta, 2000 – 2002Wakil Ketua Tim Dokter Kepresidenan RI, 2000 – 2002Wakil Ketua Tim Dokter Kepresidenan RI, 2000 – 2002Direktur Kesehatan TNI Angkatan Darat (Dirkesad), 2002-2004Direktur Kesehatan TNI Angkatan Darat (Dirkesad), 2002-2004 Wakil Ketua Tim Pemeriksaan kesehatan untuk calon Presiden dan calon Wakil Presiden RI Wakil Ketua Tim Pemeriksaan kesehatan untuk calon Presiden dan calon Wakil Presiden RI Th.2004Th.2004DOSEN Pasca Sarjana FKM UI, Kajian Administrasi Rumah Sakit (KARS)DOSEN Pasca Sarjana FKM UI, Kajian Administrasi Rumah Sakit (KARS)DIREKTUR UTAMA RUMAH SAKIT MMCDIREKTUR UTAMA RUMAH SAKIT MMC
ORGANISASIORGANISASIKetua Ikatan Rumah Sakit Jakarta Metropolitan (IRSJAM), 2000-2003Ketua Ikatan Rumah Sakit Jakarta Metropolitan (IRSJAM), 2000-2003Ketua Umum Perhimpunan Rumah Sakit Seluruh Indonesia ( PERSI), 2003-2009)Ketua Umum Perhimpunan Rumah Sakit Seluruh Indonesia ( PERSI), 2003-2009)Ketua Tim Kajian Globalisasi IDI Pusat.Ketua Tim Kajian Globalisasi IDI Pusat. Anggota Komnas FBPI. Anggota Komnas FBPI. Angggota TNP2K.Angggota TNP2K.Ketua Divisi Kemahkamahan Majelis Kehormatan Etik Kedokteran (MKEK) IDI Pusat Ketua Divisi Kemahkamahan Majelis Kehormatan Etik Kedokteran (MKEK) IDI Pusat Tim Konsultan Institut Manajemen Risiko Klinis ( IMRK )Tim Konsultan Institut Manajemen Risiko Klinis ( IMRK )Koordinator Bidang 1 : KAJIAN KESELAMATAN PASIEN, KKPRSKoordinator Bidang 1 : KAJIAN KESELAMATAN PASIEN, KKPRSInstruktur HOPE ( Hospital Preparedness for Emergencies and Disasters} Instruktur HOPE ( Hospital Preparedness for Emergencies and Disasters} PRESIDENT OF ASIAN HOSPITAL FEDERATION ( AHF ) 2009 – 2011PRESIDENT OF ASIAN HOSPITAL FEDERATION ( AHF ) 2009 – 2011
PATIENT SAFETY IS A KEY COMPONENT OF PATIENT SAFETY IS A KEY COMPONENT OF RISK MANAGEMENTRISK MANAGEMENT
Dr. ADIB A YAHYA, MARSPRESIDENT
ASIAN HOSPITAL FEDERATION( AHF )
WORKSHOP KESELAMATAN PASIEN DAN MANAJEMEN RISIKO KLINIS DI RUMAH SAKIT
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2. Why?
1. What?
3. How?
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What ?What ?
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DEFINISI RISIKODEFINISI RISIKO
RISIKO ADALAHRISIKO ADALAH : :
“ “ POTENSI TERJADINYA KERUGIAN POTENSI TERJADINYA KERUGIAN YANG DAPAT TIMBUL DARI PROSES YANG DAPAT TIMBUL DARI PROSES KEGIATAN SAAT KEGIATAN SAAT SEKARANGSEKARANG ATAU ATAU KEJADIAN KEJADIAN DIMASA DATANGDIMASA DATANG.”.”
ERM, Risk Management Handbook for Health Care OrganizationERM, Risk Management Handbook for Health Care Organization
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Risiko di Rumah SakitRisiko di Rumah Sakit
RISIKO KLINISRISIKO KLINIS : :SEMUA ISU YANG DAPAT BERDAMPAK SEMUA ISU YANG DAPAT BERDAMPAK
TERHADAP TERHADAP PENCAPAIAN PELAYANAN PASIENPENCAPAIAN PELAYANAN PASIEN YANG BERMUTU TINGGI,AMAN DAN EFEKTIF.YANG BERMUTU TINGGI,AMAN DAN EFEKTIF.
Medical staff-related risksMedical staff-related risks
Employee-related risksEmployee-related risks
Property-related risksProperty-related risks
Financial risksFinancial risks
Other risksOther risks
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Risiko yang berhubungan dengan perawatan pasienRisiko yang berhubungan dengan perawatan pasien ((Patient care related risksPatient care related risks))
Direct association with Direct association with patient carepatient careConsequences of inappropriate or incorrectly performed Consequences of inappropriate or incorrectly performed medical medical treatmentstreatmentsConfidentiality Confidentiality and appropriate release of informationand appropriate release of informationProtection from Protection from abuseabuse, , neglectneglect and assault and assaultWas patient Was patient informed of risksinformed of risks??NondiscriminatoryNondiscriminatory treatment treatmentAppropriate Appropriate triage and transfertriage and transfer of patients from ER of patients from ERPatient participation in Patient participation in research studiesresearch studies and use of experimental and use of experimental drugs - was consent obtained?drugs - was consent obtained?Was Was patient dischargedpatient discharged appropriately? appropriately?
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Risiko yang berhubungan dengan tenaga medisRisiko yang berhubungan dengan tenaga medis
((Medical staff - related risksMedical staff - related risks))
- Credential Credential terhadap staf medis ?terhadap staf medis ?
- Tindakan medis sesuai Tindakan medis sesuai kompetensikompetensi dan dan prosedur bakuprosedur baku ? ?
- - Was patient Was patient properly managed properly managed ??
- Do we have adequately - Do we have adequately trained staff trained staff ??
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Risiko yang berhubungan dengan karyawanRisiko yang berhubungan dengan karyawan
((Employee related risksEmployee related risks))
- Risiko Risiko keselamatan dan kecelakaan kerjakeselamatan dan kecelakaan kerja
- Maintaining a - Maintaining a safe environmentsafe environment - - Employee Health PolicyEmployee Health Policy : :
. reducing risk of . reducing risk of occupational illness and injuryoccupational illness and injury
. providing for the . providing for the treatment and compensationtreatment and compensation of of workers for work-related illnesses or workers for work-related illnesses or
injuriesinjuries
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Risiko yang berhubungan dengan propertyRisiko yang berhubungan dengan property ((Property related risksProperty related risks))
Protect assets from losses due to Protect assets from losses due to firesfires, , floodsfloods, etc, etc
Paper and/or electronic recordsPaper and/or electronic records - patient, business - patient, business and financial - protected from damage or and financial - protected from damage or
destructiondestruction
Procedures for Procedures for handling cashhandling cash and safeguarding and safeguarding valuablesvaluables
Bonding and Bonding and insuranceinsurance to protect facility from to protect facility from losseslosses
- - EXPOSURE AVOIDANCEEXPOSURE AVOIDANCE- LOSS PREVENTION- LOSS PREVENTION- LOSS REDUCTION- LOSS REDUCTION
- SEGREGATION (SEPARATION OR DUPLICATION)- SEGREGATION (SEPARATION OR DUPLICATION)- CONTRACTUAL TRANSFER FOR RISK CONTROL- CONTRACTUAL TRANSFER FOR RISK CONTROL
RISK FINANCINGRISK FINANCING : :
- - RISK RETENTIONRISK RETENTION- RISK TRANSFER- RISK TRANSFER
Fully trained staff to interpret and Fully trained staff to interpret and report on testsreport on tests
Clinically important results to be Clinically important results to be relayed to clinician urgentlyrelayed to clinician urgently
Ward tests to be supervised and Ward tests to be supervised and results discussed with cliniciansresults discussed with clinicians
Aware of the limits of their Aware of the limits of their competencecompetence
Senior staff to check repeatedlySenior staff to check repeatedly
Careful supervisionCareful supervision
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Reducing the risks of Reducing the risks of invasive proceduresinvasive procedures
Consider The Consider The risk : benefit ratiorisk : benefit ratio
Discuss theDiscuss the procedure with the patient procedure with the patient
Carrying out the procedure including coping with Carrying out the procedure including coping with potential difficultiespotential difficulties
Ensure that the equipment is in good working order Ensure that the equipment is in good working order and that and that back up equipmentback up equipment is available is available
If the procedure is not going well obtain If the procedure is not going well obtain help / be help / be prepared to give upprepared to give up
Ensure that the operator has Ensure that the operator has sufficient skillsufficient skill
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Reducing the risks of Reducing the risks of invasive proceduresinvasive procedures
Consider The Consider The risk : benefit ratiorisk : benefit ratio
Discuss theDiscuss the procedure with the patient procedure with the patient
Carrying out the procedure including coping with Carrying out the procedure including coping with potential difficultiespotential difficulties
Ensure that the equipment is in good working order Ensure that the equipment is in good working order and that and that back up equipmentback up equipment is available is available
If the procedure is not going well obtain If the procedure is not going well obtain help / be help / be prepared to give upprepared to give up
Ensure that the operator has Ensure that the operator has sufficient skillsufficient skill
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COMMON SPECIFIC FACTORS ASSOCIATED WITH COMMON SPECIFIC FACTORS ASSOCIATED WITH DRUG DRUG ADVERSE EVENTSADVERSE EVENTS
FAILURE TO TAKE ACCOUNT OF DECLINING FAILURE TO TAKE ACCOUNT OF DECLINING RENAL / HEPATIC FUNCTIONRENAL / HEPATIC FUNCTION
FAILURE TO CHECK FOR POSSIBLE FAILURE TO CHECK FOR POSSIBLE ALLERGIC ALLERGIC RESPONSESRESPONSES
USING THE USING THE WRONG DRUG NAMEWRONG DRUG NAME OR MEANS OF OR MEANS OF ADMINISTRATIONADMINISTRATION
MISCALCULATION OF MISCALCULATION OF DOSAGEDOSAGE
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REDUCING THE RISKS OF ONGOING REDUCING THE RISKS OF ONGOING WARD CAREWARD CARE
POTENTIAL ERRORSPOTENTIAL ERRORS
Failure to Failure to monitormonitor clinical clinical progressprogress
Failure to recognise that a Failure to recognise that a patient is patient is not making not making satisfactory progresssatisfactory progress
Failure to provide Failure to provide appropriate appropriate treatmenttreatment
Use spesialist staff – clinician Use spesialist staff – clinician from appropriate unit, nurse from appropriate unit, nurse spesialist, physiotherapistspesialist, physiotherapist
PATIENT SAFETY,QUALITY OF CAREPATIENT SAFETY,QUALITY OF CARE
AND RISK MANAGEMENTAND RISK MANAGEMENT
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The basic principles for safety The basic principles for safety and quality of careand quality of care
The basic principles for patient safety are The basic principles for patient safety are the the principles for quality of careprinciples for quality of care: :
- to - to do the right thingdo the right thing
for the for the right patientright patient
using the using the right methodright method and and
at the at the right timeright time, and , and
- to - to communicate wellcommunicate well with the with the patient patient and the rest of the and the rest of the clinical teamclinical team
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““It’s easy gettin’ good players.It’s easy gettin’ good players.The hard part is gettin’ them to play The hard part is gettin’ them to play
with each other”with each other”
(Casey Stengel)
(Casey
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Communicating Team ???Communicating Team ???
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Quality in HealthcareQuality in Healthcare
……. begins with . begins with ensuring patient safetyensuring patient safety
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Key reasonsKey reasons
Patients are Patients are more at riskmore at risk than non-patients than non-patients
Medical interventions are, by their nature, Medical interventions are, by their nature, high-risk procedures - high-risk procedures - small error small error
marginsmargins
Medicine remains an Medicine remains an inexactinexact, hands-on , hands-on endeavourendeavour
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Patient safety in contextPatient safety in context
Patient safetyPatient safety is an important component of is an important component of
risk managementrisk management, , clinical governanceclinical governance, and , and quality improvementquality improvement. .
4343Australian Patient Safety Foundation
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I. Risk management is not primarily about avoiding or mitigating claims; rather, it is a tool for
improving the quality of care.
II. Incident reporting is only one aspect of the identification of risk. Incident reporting is on the reactive side of risk management. More emphasis needs to be placed on
the proactive side. III. Risk management is actually
the business of all stakeholders in the organisation, clinicians and nonclinicians.
IV. The primary focus of risk management should now be
clinical governance and patient safety.
CONCLUSIONSCONCLUSIONS
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FINAL WORDFINAL WORD
……Safe care is not an option. It is the right of every patient
who entrusts their care to our Healthcare systems…Sir Liam Donaldson,
Chair, WHO World Alliance for Patient Safety, Forward Programme, 2006–2007