8/16/2019 Format Laporan Keselamatan Psn ( Revisi Terbaru )

1/2

TIM KESELAMATAN PASIEN RUMAH SAKIT

RAHASIA, TIDAK BOLEH DIFOTOCOPY, DILAPORKAN MAXIMAL 2 X 24 JAM

LAPORAN INSIDEN

(INTERNAL)I. DATA PASIEN

Nama : ........................................................................................................N MR : ...................................... R!a"#a" : ............................................Um!$%

J&"' K& am'": La*'+ a*'

P&$&m !a"

B&$a- Ba a" : /............... K#

Ka- $' : B&$0a* 1a*'" A *& *'" SKTM S3a -a (P$' a ') S3a -a Jam'"a"

A *& A"#*a-a" A *& N " D& a$-&m&"T# . Ma !* RS : ........................................................................................................

II. RINCIAN KEJADIAN1. Tanggal dan Waktu Kejadian :

Ta"##a : /////..///////////Jam................................................

2. Insiden :////////////////////////////////

3. K !n!l!gis Insiden :......................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

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

Ti"e Insiden# : K&5a 'a" T' a* D'0a$a *a" KTD ( Adverse Event ) K&5a 'a" N6a$' C& &$a KNC ( Near miss )

$. % ang Pe ta&a 'ang (ela"! kan Insiden# : Ka$6a3a" (D *-&$ P&$a3a- P&-!#a La'") Pa '&" K& !a$#a P&" am '"# Pa '&" P&"#!"5!"# La'"+ a'" ................................................................................................... ( & !-*a" )

). Insiden te jadi "ada# : Pa '&" Ka$6a3a" D *-&$ P&"#!"5!"# R!ma0 Sa*'- P&" am '"# a '&" *& !a$#a

*. Te&"at Insiden :L *a ' K&5a 'a" : ............................................................................................................

7+8 ! a" 9 8 ! a" 8 -a0!" 9 8 -a0!" ; -a0!" 9 ; -a0!" 8; -a0!" 9 8; -a0!"

8/16/2019 Format Laporan Keselamatan Psn ( Revisi Terbaru )

2/2

+. Insiden te jadi "ada "asien : , sesuai kasus "en-akit s"esialisasi /..........................................................................................................................................

0. nit De"a te&en te kait -ang &en-e a kan insidenU"'- *&$5a &"6& a .........................................................................................................

. Aki at Insiden Te 4ada" Pasien# : K&ma-'a" C& &$a I$$&>&$ ' & C& &$a B&$a- C& &$a R&>&$ ' & C& &$a S& a"# C& &$a R'"#a" T' a* a a ?& &$a

15. Tindakan -ang dilakukan sege a setela4 kejadian6 dan 4asiln-a :....................................................................................................................................................................................................................................................................................

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

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

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

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

11. Tindakan Dilakukan !le4 % : T'm , -&$ '$' a$' : .......................................................................................................... D *-&$ P&$a3a- P&-!#a a'""6a ...........................................................................................................

12. A"aka4 kejadian -ang sa&a "e na4 te jadi di nit Ke ja lain 7# Ya T' a*

A a ' a 6a, ' ' a0 6a"# ' a3a0 '"'.Ka a" @ a" La"#*a0 -'" a*a" a a 6a"# -& a0 'am ' a a U"'- *&$5a -&$ & !- !"-!*m&"?a0 -&$! a"#"6a *&5a 'a" 6a"# ama @..................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................................

P&m !a- La $a" : ................................ P&"&$'ma La $a" : ...............................

Pa$a : ................................ Pa$a : ...............................

T# T&$'ma : ................................ T# La $ : ...............................

8 ading Resik! Kejadian# (D'' ' &0 a-a a" & a $) : 9IR IJA K NIN8 (ERA

NB.% ' '0 a a0 a-! 5a3a a".