Criterion 5.4.1 IKP REPORTING

 Standard 5.4 Reporting patient safety incidents and developing a safety culture

The Community Health Center establishes a patient safety incident reporting system and develops a safety culture.

Reporting patient safety incidents is related to the safety culture at the Community Health Center and is necessary to prevent further or repeated incidents in the future which will have a greater detrimental impact on the Community Health Center.

a. Criterion 5.4.1

Reporting, documentation, root cause analysis and preparation of corrective actions are carried out as an effort to improve and prevent potential patient safety incidents.

1) Main Thoughts:

a) A patient safety incident is any unintentional event and condition that results in or has the potential to result in preventable injury to a patient.

b) Patient safety incidents consist of (1) significant potential injury conditions (KPCS), (2) near injury events (KNC), (3) non-injury events (KTC), (4) unexpected events (KTD), and ( 5) sentinel event (KS).

c) Patient safety measures are taken to prevent incidents from occurring. The incident type consists of the following incidents:

(1) Unexpected events (KTD) are incidents that result in injury to the patient. For example, a patient falls out of bed and injures his ankle.

(2) Non-injury events (KTC) are incidents that have affected/exposed the patient, but no injury occurred. For example, a nurse gives the wrong medicine to a patient, the medicine has been taken, but the patient is not injured.

(3) Potentially significant injury conditions (KPCS) are all situations or related conditions (other than disease processes) that have the potential to cause significant injury/sentinel events. For example, a damaged DC shock, although there are no patients yet, has the potential to cause significant injury.

(4) A near miss (KNC) is an incident that occurs, but has not affected/been exposed to the patient because it can be prevented. For example, when a nurse wants to give medicine to a patient, when checking, it turns out that the medicine given by the pharmacy is another patient's medicine with a similar name so the medicine is not given.

(5) Sentinel is an undesirable event that results in death or serious injury. Sentinel events can be:

(a) unexpected death, including but not limited to

1. death that is not related to the course of the disease or the patient's condition (for example: death due to late transfer process);

2. term infant death; And

3. suicide;

(b) permanent loss of function unrelated to the patient's disease or condition;

(c) wrong side action, wrong procedure, and wrong patient;

(d) kidnapping of children, including babies or children being sent to a house other than their parents' home; And

(e) rape, workplace cruelty such as assault (resulting in death or permanent loss of function) or murder (intentional) of patients, family members, staff, doctors, visitors, or vendors/third parties while within the Puskesmas environment.

d) Patient safety incident reporting, hereinafter referred to as incident reporting, is a system for documenting patient safety incident reports. Incident reporting consists of internal incident reports and external incident reports.

e) The reporting system is expected to encourage individuals within the Community Health Center to care about dangers or potential dangers that could occur to patients. Reporting is also important to monitor efforts to prevent errors so that it can encourage investigations. On the other hand, reporting will be the start of a learning process to prevent the same incident from happening again.

f) Community Health Centers need to carry out an analysis using a risk grading matrix which will determine the type of incident investigation carried out after an internal incident report. Investigations consist of simple investigations and investigations with Root Cause Analysis (RCA). Investigations using root cause analysis (RCA) consist of simple investigations (for green and blue risk grading) and comprehensive investigations (for red and yellow risk grading). In sentinel events there is no need to consider color grading.

g) Community health centers need to establish a community health center patient safety learning reporting system (SP2KPP) for incidents which includes policies, reporting flow, reporting forms, reporting procedures, incidents that must be reported internally, namely all types of incidents including sentinel events, unexpected events, near-miss incidents, non-injury events and significant potential injury events. Meanwhile, the external reports reported are IKP which includes the types of unforeseen accidents and sentinel incidents for which root cause analysis (RCA) and corrective action plans have been carried out. It is also determined who makes the report, the reporting deadline, investigation and follow-up.

h) Reporting of patient safety incidents is reported in accordance with statutory provisions.

2) Assessment Elements:

a) Reporting is carried out if an incident occurs in accordance with established policies and procedures to the patient safety team and head of the health center accompanied by analysis, incident investigation and follow-up on incidents (R,D,W).

b) Reporting to the National Patient Safety Committee (KNKP) regarding incidents, analysis and follow-up is carried out in accordance with the specified time frame (D, O, W).