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Formulir Laporan Insiden ke Tim KP di RSRumah Sakit ...................................

RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAXIMAL 2 x 2 !AM

LAPORAN INSIDEN"INTERNAL#

I. DATA PASIENNama

$ .........................................................................................................No MR $ ......................................... Ruangan$ .............................................%mu& ' $ ()* +ua- * +ua- / * tahu-

* tahu- / 0 tahu- 0 tahu- / *0 tahu-

*0 tahu- / 1( tahu- 1( tahu- / 0 tahu- 0 tahu-

!3-i4 k3ami- $ Laki)aki P3&3m5ua-P3-a-66u-6 +ia7a 5a4i3- $

P&i+a8i A4u&a-4iBP!S P3&u4ahaa-'

Ta-66a Ma4uk RS $ ............................................................................!am .....................................

II. RINCIAN KEADIAN

*. Ta-66a 8a- 9aktu I-4i83-Ta-66a $ ........................................................................................!am ......................................

2.I-4i83- $ ..........................................................................................................................................

1. K&:-::6i4 I-4i83-.......................................................................................................................................................

.....................................................................................................................

..................................

.....................................................................................................................

..................................

. !3-i4 I-4i83-' $ K3;a8ia- N7a&i4 C383&a < KNC (Near miss) Kejadian Tidak cedera / KTC (No Harm)

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K3;a8ia- Ti8ak 8iha&a5ka- < KTD (Adverse Event)

0. O&a-6 P3&tama Ya-6 M3a5:&ka- I-4i83-'Ka&7a=a- $ D:kt3& < P3&a=at < P3tu6a4 ai--7aPa4i3-

K3ua&6a < P3-8am5i-6 5a4i3-P3-6u-;u-6Lai-)ai- ...........................................................................................!se"u#kan$

. I-4i83- t3&;a8i 5a8a' $Pa4i3-Lai-)ai- .............................................................................................................!se"u#kan$

Mi4 $ ka&7a=a- < P3-6u-;u-6 < P3-8am5i-6 < K3ua&6a 5a4i3-, a5:& k3K1 RS.

>. I-4i83- m3-7a-6kut 5a4i3- $Pa4i3- &a=at i-a5Pa4i3- &a=at ;aa-Pa4i3- I?DLai-)ai- .............................................................................................................!se"u#kan$

%. Tempa# InsidenL:ka4ik3;a8ia- ...................................................................................................!se"u#kan$"T3m5at 5a4i3- +3&a8a#

@. Insiden #er&adi pada pasien ' !sesuai kasus pen(aki# ) spesialisasi$P3-7akit Daam 8a- Su+4534iai4a4i-7aA-ak 8a- Su+4534iai4a4i-7aB38ah 8a- Su+4534iai4a4i-7aO+4t3t&i ?7-3k::6i 8a- Su+4534iai4a4i-7aTHT 8a- Su+4534iai4a4i-7aMata 8a- Su+4534iai4a4i-7aSa&a 8a- Su+4534iai4a4i-7aA-a4t34i 8a- Su+4534iai4a4i-7aKuit K3ami- 8a- Su+4534iai4a4i-7a!a-tu-6 8a- Su+4534iai4a4i-7aPa&u 8a- Su+4534iai4a4i-7a!i=a 8a- Su+4534iai4a4i-7a

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Lai-)ai- ...........................................................................................................!se"u#kan$

*+. ,ni# ) Depar#emen #erkai# (ang men(e"a"kan insiden

%-it k3&;a53-73+a+ ...........................................................................................!se"u#kan$

**. Aki"a# Insiden Ter-adap Pasien 'K3matia-C383&a I&&33&4i+3 < C383&a B3&atC383&a R33&4i+3 < C383&a S38a-6C383&a Ri-6a-Ti8ak a8a 383&a

*/. Tindakan (ang dilakukan segera se#ela- ke&adian0 dan -asiln(a '..................................................................................................................................................................................................................................................................................................................................................................................................................................................................

*1. Tindakan dilakukan ole- 'Tim $ t3&8i&i8a&i $ ..................................................................................................................D:kt3&P3&a=atP3tu6a4ai--7a .....................................................................................................................

*2. Apaka- ke&adian (ang sama perna- #er&adi di ,ni# Ker&a lain3Ya Ti8akA5a+ia 7a, i4i +a6ia- 8i+a=ah i-i.Kapan 3 dan Langka- ) #indakan apa (ang #ela- diam"il pada ,ni#ker&a #erse"u#un#uk men4ega- #erulangn(a ke&adian (ang sama3............................................................................................................................................................................................................................................................................................................

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5rading Risiko Ke&adian "Dii4i :3h ata4a- 53a5: $ 6IR, 7IA, K,NIN5 COKLAT MERA7NB. ' 5iih 4atu ;a=a+a-

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?&a8i-6 Ri4ik: K3;a8ia-' "Dii4i :3h ata4a- 53a5: $ BIR% HI!A% K%NIN? MERAHTi-8ak a-;ut' "Dii4i :3h ata4a- 53a5: $ I-34ti6a4i 4383&ha-a * mi-66u I-34ti6a4i S383&ha-a 2 mi-66u RCA 0 ha&iNB. ' 5iih 4atu ;a=a+a-

P3m+uat La5:&a- P3-3&ima La5:&a-

Pa&a Pa&a T6 La5:& T6 t3&ima

KPRS< K:mit3 K343amata- Pa4i3- Rumah SakitHa4i $ ?&a8i-6 Ri4ik: K3;a8ia- $ BIR% HI!A% K%NIN? MERAHTi-8ak a-;ut$ I-34ti6a4i 4383&ha-a * mi-66u I-34ti6a4i S383&ha-a 2 mi-66u RCA 0 ha&i

Nama

T3&a-6

$

Ta-8a

Ta-6a-

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Ta-66a

!am