Formulir Laporan Insiden Keselamatan Pasien RS (Eksternal)

 

KOMITE KESELAMATAN PASIEN RUMAH SAKIT (KKPRS-PERSI) TIM KESELAMAT KE SELAMATAN AN PASIEN RUMAH SAKIT HAJ HAJII JAKARTA Jalan Raya Pondok Gede No. 4, Jaka!a T"#$ %&' No. Tel*. Tel*. +%-, a. +%- RAHASIA

ORMULIR LAPORAN INSIEN KESELAMATAN PASIEN RUMAH SAKIT KODE RUMAH SAKIT : .......................

(Lewat : http://www.inapat-safety.o.i!  /pos/"#i$

I.

ATA RUMAH SAKIT /

Ke*e#"l"kan R$#a0 Sak"! / 

%e&eintah %#sat



%e&eintah Daeah (%opinsi / Ka'. / Kota$



TI / %OLRI



Swasta



)UM / )UMD

Jen"1 RS / 

RS U&#&



RS Kh#s#s



RSIA



RS %a#



RS Mata



RS Othope!i



RS *ant#n+



RS *iwa



RS K#sta



RS Kh#s#s ,ainnya ............................................ ................................................................... .............................................. .........................

Kela1 RS 

A



)

 

KOMITE KESELAMATAN PASIEN RUMAH SAKIT (KKPRS-PERSI) TIM KESELAMAT KE SELAMATAN AN PASIEN RUMAH SAKIT HAJ HAJII JAKARTA Jalan Raya Pondok Gede No. 4, Jaka!a T"#$ %&' No. Tel*. Tel*. +%-, a. +%-







D

Kapasitas Kapasit as Te&pat Te&pat Ti Ti!# !#

: .......... ............... .......... .......... ..... Te&pat Ti!#  Ti!# 

%op %opin insi si (Lo"a (Lo"asi si RS$

: ...... ........ .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... .... ..

Tan++a, Lapoan Insi!en !i"ii& "e KK%RS-%esi : ................................................ ................................................

II. ATA PASIEN U#$ 2

Jen"1 Kela#"n

/    0 tah#n

1 0 '#,an  0 tah#n

  1 0 tah#n  2 tah#n

1 2 tah#n  02 tah#n

  1 02 tah#n  3 tah#n

1 3 tah#n  42 tah#n

  1 42 tah#n /  La"i-,a"i

%ee&p#an

Penan33$n3 "aya *a1"en /   %i'a!i

As#ansi Swasta

  ASKES %e&eintah %e#sahaan 5   Tan33al Ma1$k RS

*AMKESMAS / ............................................ Ja# ..................................

III. RIN5IAN KEJAIAN 0. Tan33al dan 6ak!$ In1"den Tan++a, an++a,

: ...... ......... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ..... *a& ...... ......... ...... ...... ...... ...... ...... ...... ...... ...... ...

6.

In1"den

........................................... .............................................. .............................................. .................................. ........... / ....................

3.

Konolo3"1 In1"den

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

 

KOMITE KESELAMATAN PASIEN RUMAH SAKIT (KKPRS-PERSI) TIM KESELAMAT KE SELAMATAN AN PASIEN RUMAH SAKIT HAJ HAJII JAKARTA Jalan Raya Pondok Gede No. 4, Jaka!a T"#$ %&' No. Tel*. Tel*. +%-, a. +%-

7.

Jen"1 In1"den2 /

 Ke8a!ian yais e!ea / K ( Near miss)  Ke8a!ian Ti!a" Ti!a" Dihaap"an Dihaap"an / KTD (Adverse Event)  Event)  / Ke8a!ian Sentine, (Sentinel   Event) 2.

Oan3 Pe!a#a 7an3 Mela*okan In1"den2

 Kayawan : Do"te / %eawat / %et#+as ,ainnya  %asien Ke,#a+a / %en!a&pin+ %asien  %en+#n8#n+  Lain-,ain ........................................... .................................................................. .............................................. .........................(se'#t"an$ ..(se'#t"an$ In1"den !e8ad" *ada2 / 4.  %asien

 Lain-,ain ........................................... .................................................................. .............................................. .........................(se'#t"an$ ..(se'#t"an$ Mis. : Kayawan / %en+#n8#n+ / %en!a&pin+ / Ke,#a+a %asien9 ,apo "e K3 RS .

In1"den #enyan3k$! *a1"en /

 %asien awat inap  %asien awat 8a,an  %asien U;D  Lain-,ain ........................................... .................................................................. .............................................. .........................(se'#t"an$ ..(se'#t"an$ Te#*a! In1"den I n1"den