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Nama : Muhammad Satya Arrif Z Topik : Patients safety in hospital Problem (Woolf, 2004) These errors in addressing extant risks arguably are more threatening to health than lapses in safety. Although “To Err Is Human” (1) suggested that 44 000 to 98 000 Americans die each year because of medical errors, more careful analyses suggest that only a fraction of these deaths, perhaps fewer than 5%, are causally linked to errors (18-20). Only a subset of adverse drug events, the first concern of the patient safety movement, causes serious harm (21). A cohort study of Medicare beneficiaries noted 5 life-threatening or fatal preventable adverse drug events for every 1000 person-years of observation (22). (Streimelweger et al., 2015) Human errors are one main source for accidents in any industry including health care. According to Reason, particularly important is the identification of cognitive processes common to a wide variety of human error types. These errors are differentiated into variable and constant6 errors and are classified as active and latent failures. (Erickson, 2014) (Miake-Lye et al., 2013) The rate of falls in acute care hospitals ranges from approximately 1 to 9 per 1000 bed-days High-quality evidence shows that multicomponent interventions can reduce risk for in-hospital falls by as much as 30%. Definition (Emanuel et al., 2008) Patient safety is a discipline in the health care sector that applies safety science methods toward the goal of achieving a trustworthy system of health care delivery. Patient safety is also an attribute of health care systems; it minimizes the incidence and impact of, and maximizes recovery from, adverse events. This definition acknowledges that patient safety is both a way of doing things and an emergent discipline. It seeks to identify essential features of patient safety. Patient safety in five areas: (Donaldson et al., 2014) -efforts to create and enforce new safety standards through regulation and accreditation; -weaknesses in how health systems track and report errors; the disappointing uptake of promising information technology (IT) tools that promote patient safety; -the lack of progress in reforming the U.S. medical malpractice landscape and fostering increased accountability among health care providers -the paucity of physician and nurse engagement in patient safety efforts Patients safety indicator (McDonald et al., 2002) Function / Objective (Wong, 2017) - Improve the accuracy of patient identification. -Improve the effectiveness of communication among caregivers. -Improve the safety of using medications. -Reduce the harm associated with clinical alarm systems. -Reduce the risk of health care – associated infections. - The hospital identifies safety risks inherent in its patient population. Example and application (Gillespie et al., 2014) checklists are associated with a reduction in overall complications in surgical patients. Surgical safety checklists provide a means to safeguard patients and minimize risk through increased team cohesion and coordination. Importantly checklists should be used to augment, and not replace, other initiatives that contribute to a safety culture Penggunaan ceklis pada pasien dengan tindakan bedah secara umum akan menurunkan komplikasi. Ceklis keselamatan operasi menyediakan keselamatan pasiendan meminimalisasikan resiko dengan meningkatkan keterpaduan dan koordinasi antar team (Weaver et al., 2013) Promotion of patient safety culture can best be conceptualized as a constellation of interventions rooted in principles of leadership, teamwork, and behavior change, rather than a specific process, team, or technology. Strategies to promote a culture of patient safety may include a single intervention or several interventions combined into a multifaceted approach or series. They may also include system-level changes, such as those in governance or reporting structure. For example, team training, interdisciplinary rounding or executive walk rounds, and unit-based strategies that include a series of interventions have all been labeled as interventions to promote a culture of safety. Team training refers to a set of structured methods for optimizing teamwork processes, such as communication, cooperation, collaboration, and leadership (Winters et al., 2013) Rapid-response systems (RRSs) were created to improve recognition of and response to deterioration of patients on general hospital wards, with the goal of reducing the incidence of cardiorespiratory arrest and hospital mortality. An RRS generally has 3 components. 1) Criteria and a system for notifying and activating the response team (known as an “afferent limb,” the mechanism by which team responses are triggered). Activation criteria usually include vital signs (single-trigger criteria vs. aggregate and weighted early warning scoring) or general concern expressed by a clinician or family member. The afferent limb defines the variables that indicate deterioration and democratizes that knowledge to all clinicians. It also empowers bedside clinicians to trigger the response team (or “efferent limb,” the team of clinicians that respond to an event) when the clinician has a suspicion that a patient is deteriorating (2). As such, most RRSs rely on clinicians to proactively identify deteriorating patients rather than solely on continuous monitoring technology, which is common in the intensive care unit (ICU). 2) The response team (efferent limb) . The response team most frequently comprises ICU-trained personnel and equipment. Team composition varies on the basis of local needs and resources but generally uses one of the following models: medical emergency teams (METs), which include a physician; rapid-response teams, which do not include a physician; and critical care outreach teams, which follow up on patients discharged from an ICU but also respond to all ward patients. 3) An administrative and quality improvement component . This team collects and analyzes event data and provides feedback, coordinates resources, and ensures improvement or maintenance over time. (Kim et al., 2013) Essential specimen handling steps. Blue items are physician-specific responsibilities; pink items are nursing staffespecific responsibilities.
