Healthcare Failure Mode Effect and Analysis (HFMEA): Proses Pelayanan Pasien Operasi di Rumah Sakit X

Indiati (2012) Healthcare Failure Mode Effect and Analysis (HFMEA): Proses Pelayanan Pasien Operasi di Rumah Sakit X. Magister thesis, Universitas Brawijaya.

Abstract

Latar belakang : Sebagian besar kejadian medical error di Rumah Sakit X merupakan preventable incident. Keberhasilan pencegahan terletak pada kemampuan sistem untuk mengidentifikasi potensi risiko kejadian sedini mungkin dan menetapkan suatu mekanisme barrier . Tujuan : Mengidentifikasi risiko insiden keselamatan pasien ( failure mode ) pelayanan pasien operasi, penyebab failure mode disetiap tahapan proses dan strategi pencegahannya. Metode : Menggunakan Healthcare Failure Mode Effect And Analysis (HFMEA) pada proses pasien operasi. Cara pengumpulan data dengan melakukan observasi, wawancara, pemeriksaan dokumen dan diskusi kelompok terfokus (FGD) terhadap kelompok dokter jaga, dokter spesialis, perawat kamar operasi, dan informan pendukung petugas laborat, petugas radiologi, kabid keperawatan, total informan ada 18 orang. Fokus penelitian adalah proses pelayanan pasien operasi di rawat inap dan di kamar operasi. Hasil : Hasil penelitian menunjukkan alur proses pelayanan pasien operasi di RS X terdiri dari tujuh subproses yang terbagi atas 29 aktivitas. Terdapat 25 aktivitas yang tidak dilakukan dengan lengkap menimbulkan 26 risiko potensial kegagalan. Faktor penyebab terjadinya potensi risiko adalah kompetensi perawat yang kurang, tidak adanya dokter operator tetap, kurangnya supervisi, monitor dan evaluasi serta banyaknya transisi yang mendorong terjadinya pengabaian prosedur komunikasi pada setiap transisi antar bagian atau antar shift. Semua faktor menggambarkan belum berkembangnya budaya patient safety pada dimensi organizational learning, hospital handoffs and transitions ( serah terima), o penness (keterbukaan), respon non-punitif terhadap kesalahan, frekuensi pelaporan kejadian. Kesimpulan: Manajemen perlu melakukan redesign proses pelayanan pasien operasi, pengembangan budaya patient safety meliputi pelatihan komunikasi dan refreshing berkala, pemenuhan kualifikasi tenaga perawat dan pengadaan dokter operator tetap.

English Abstract

Background: Most of medical errors are preventable incident. The fact of high adverse event and near miss in X Hospital also show chance for improvement by implementing patient safety management, emphasizing in system approach and prevention focus. The success in prevention and system approach is based on the ability of system to identify potential risk, recognize event as early as possible, and set a barrier mechanism. Objective: This research was aimed to identify the risk patient safety incident (Failure Mode), in patient caring process which is undergo operation, the cause of failure mode in every stage and prevention strategy. Methods: Using healthcare failure mode effect and analysis (HFMEA)surgical patient process.The data collected by observation (time motion study in surgery prepotition and procedure), interviews (surgeon, general practition, analyst, radiographer, nurses), study document and Focus Group Discussions (FGD). The focus of this research is the surgery process in wards and operating theatre. Result: The result of research identify 7 subprocess 29 activities in surgery process, but there are 25 activities which were not performed or incomplete performed lead to 26 potential failure risk. The underlying cause of potential risk in most subprocess is ineffective communiation. It`s caused by neglected or violation, due to frequent transition among departments and between shift, lack of supervision, lack of competency nurse, and no stand by surgeon. These finding reveal lack of patient safety culture. Conclusion: Management needs to redesign surgery process, develop patient safety culture by communication training and regular refreshing, continues program development, and recruit stand by surgeon in order to minimize potential failure risk in patient surgery care in X Hospital.

Item Type:	Thesis (Magister)
Identification Number:	TES/610/IND/h/041204287
Subjects:	600 Technology (Applied sciences) > 610 Medicine and health
Divisions:	S2/S3 > Magister Manajemen Rumah Sakit, Fakultas Kedokteran
Depositing User:	Endro Setyobudi
Date Deposited:	08 Feb 2013 13:00
Last Modified:	02 Feb 2023 02:28
URI:	http://repository.ub.ac.id/id/eprint/157951

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