1. WEDNESDAY, AUGUST 31st 2022
MORNING REPORT
QUALITY IMPROVEMENT
AND PATIENT SAFETY
RSUP PROF. Dr. I.G.N.G NGOERAH
2. INTERNATIONAL SERVICES PATIENT SAFETY GOAL
(IPSG)
• IPSG 1. Correct Patient Identification
• IPSG 2. Improving Effective Communication
• IPSG 3. Improving the safety of the use of drugs that require
attention
• IPSG 4. Reduces the Risk of Wrong Locations, Wrong Patients and
Operations
• IPSG 5. Reduces the Risk of Infection
• IPSG 6. Reducing the Patient's Risk of Injury Due to Falls
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
3. IPSG 1. Correct Patient Identification
• Identification with two
identities (name and date of
birth)
• Identify “4 Before”
• Identity bracelet
• Etiquette on food, drink,
medicine
• Bracelet color
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
In Patient
4. Patient's ID
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
Name
Date of Birth
Medical Record Number
5. 4 BEFORE
• Before medications administration
• Before bloods/other blood products administrations
• Before taking any sample (blood, urine, sputum)
• Before doing the procedure
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
6. Identity bracelet should be attached on
• Inpatients
• Hemodialysis patients
• Emergency patients
• Patients who will going on procedure/s
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
7. Make sure every medicine etiquette have to be consist 2 out of 4 :
• Name
• Date of birth
• Medical record number
• Residential register number (NIK)
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
8. Identity bracelet color
• Pink bracelet : for female
• Blue sky bracelet : for male
• Yellow bracelet : FALLS RISK
• Red bracelet : allergy
• Purple bracelet : do not resuscitate
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
9. IPSG 2. Improving effective communication
• Critical patient communication by telephone, hand over, and
patient transfer between rooms using the SBAR communication
method
• Do Read Back when receiving verbal orders over the phone, put a
Sign Here sticker, signed by the doctor who gave the instructions
• Abbreviations according to the list of abbreviations
• Writing can be read by at least two people
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
10. SBAR
• S = Situation (a concise statement of the
problem)
• B = Background (pertinent and brief
information related to the situation)
• A = Assessment (analysis and considerations
of options — what you found/think)
• R = Recommendation (action
requested/recommended — what you want)
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
11. READ BACK & SIGN HERE
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
There is no read back and
sign here for this patient
13. IPSG 3. Improving the safety of the use of drugs that require
attention
• Improve the safety of High Alert Medications (LASA : Look Alike Sound
Alike) Medications
• High alert medications stored in a locked cabinet separated from other
medications
• Do double check 5 R related, medicine distribution and administration
(ID, name, dose, route, time of administration)
• Medicine administration have to be 6 rights (patients, medicine, dose,
time of administration, route of administration, expired date)
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
16. List of High Alert Medicines
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
17. 5 R
Ra + Ri + Ru + Re + Ro
1. Rajin
2. Rapi
3. Rawat
4. Resik
5. Ringkes
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
18. 6 RIGHTS
• Right Patients identify patient's name and date of birth
• Right Medicine cross check doctor's instruction and name on the medicine
• Right Dosage cross check doctor's instructions and medicine dosage
• Right Time cross check doctor's instructions and note on the medicine
Ask questions if the medication is being given at a different time than usual
(before/after meal + if needed + etc)
• Right Route of Administration cross check the doctor's instruction and
medicines (oral / sublingual / parenteral / topical)
• Right Documentation signature from 2 nurse on medicine's note
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
19. IPSG 4. Ensure correct-site , correct-procedure , correct-patient
surgery
• Marking surgical site that has 2 sides involving laterality (right, left),
multiple structures or multiple level or regions
• Made by the doctor who perform the procedure, involving patient and
family. Written using waterproof skin marker when explain pre
operative informed consent
• The result of the marking inform consent written on the integrated
education form
• Do Patients Safety checklist which is :Sign In, Time Out & Sign Out
throughout the entire hopital (OR, cath lab)
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
20. SURGICAL / SITE MARKING
SINISTRA
(LEFT)
DEXTRA
(RIGHT)
S
D
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
21. INTEGRATED EDUCATION FORM
• educator's sign
• family's sign
O = Observations
C = Ceramah
D = Diskusi
S = Simulasi
PL = Praktek Langsung
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
22. IPSG 5. Reduce The Risk of Health Care-
Associated Infections
• Do Hand Hygiene, 6 steps and 5 moments
• When installing invasive tools : write time of administration
• Make sure every tools used in sterile conditions
• Changing invasive tools: infusion every 3x24 hours, other tools
(Dower's catheter, NGT, WSD, CVC, ETT) every 2 weeks, do
immediate change if there is any sign of infections
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
23. HAND HYGIENE
• Hand Washing : using running water & hand soap
• Hand Rubbing : using antiseptic alcohol based
• Clean your hands by rubbing them with an alcohol-based formulation,
as the preferred mean for routine hygienic hand antisepsis if hands are
not visibly soiled. 5-10 times, after that wash with soap and water.
• Wash your hands with soap and water when hands are visibly dirty or
visibly soiled with blood or other body fluids or after using the toilet.
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
24. 6 STEPS OF HAND WASHING
1. Apply enough soap to cover all
hand surfaces
2. Rub hands palm to palm
3. Right palm over left dorsum with
interlaced fingers and vice versa
4. Palm to palm with fingers
interlaced
5. Backs of fingers to opposing
palms with fingers interlocked
6. Rotational rubbing of left thumb
clasped in right palm and vice
versa
7. Rotational rubbing, backwards
and forwards with clasped fingers
of right hand in left palm and vice
versa
Hand washing for 40-60 seconds,
Hand rub for 20-30 seconds
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
25. 5 MOMENTS OF HAND WASHING
• Expired of the hand rub after
opening 1 year
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
26. DATE WRITING ON INVASIVE TOOLS
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
27. IPSG 6. Reduce the Risk of Patient's Injury due to Falls
• Assesing all patients who
has high risk for falls
• Use risk for falls form to
measure (adult using
Morse, child using
Humpty Dumpty,
psychiatric patients using
Edmonson)
• Attach yellow bracelet
and put a symbol on
patients who has high
risk for falls
• Do implementations
using high risk for falls
protocols
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
In Patient
28. ASSSESMENT ON FALLS RISK
• every new patients
• every shift
• every changing conditions
• yellow bracelet if Morse score > 25,
Humpty Dumpty score >12 and
Edmonson score >90
SMF ILMU KESEHATAN ANAK RSUP SANGLAH 2016
30. “To become the leading institution for pediatric specialist
that produces graduates with the highest competency,
integrity and cultured as well as able to compete
internationally by 2025”
VISION
31. MISSION
1
2
3
Conducting continuous education and training in the field of pediatric
utilizing education system platform to produce graduates who has the
highest regard to moral and ethical values and the highest integrity in
accordance to local, national, and international standards
Conducting world class research in the field of pediatric
Conducting community works in accordance to the need of the people of
Indonesia
32. QUALITY INDICATION OF
INPATIENTS
Giving information about assesment, diagnosis, and planning for
patients and family on new cancer cases 100%
Percentage of time out chemotherapy 100%
Effort on preventing fall risks due to patients fall 100%
RSUP PROF. Dr. I.G.N.G NGOERAH
34. Identity Sheet that has been
signed by Admission Employee
PATIENTS IDENTITY
SHEET
35. This photo was taken
by parent's permissions
PATIENTS PHOTO
36. BRACELET ATTACHMENT
Patient's Identity Bracelet
Blue bracelet show that the patient's
gender is male
Yellow bracelet show that the patient’s
has high risk for falls
Identity bracelet consist of medical record's
number + name + gender + age and date of
birth
38. GENERAL CONSENT
General Consent which has been signed by the patient's family and admission officer
General Consent Summary:
1. Patients' rights and obligations during hospitalization
2. During treatment, the patient will be interviewed, physical examination, supporting
examination, which then the results of the examination will be informed to patients and
families
3. Patients can refuse action during treatment If a high-risk procedure is to be carried out
4. The patient and family will be informed in advance and required approval from the
family in the form of a signature
5. If a low-risk action is to be taken, it is enough to ask for verbal approval
6. In the treatment process, there will be students who take care of the patient
7. If the patient/family has a complaint, it can be submitted directly through oral and
written
8. Hospitals are only responsible for maintaining goods for patients who do not
accompanied by family
9. The hospital maintains the confidentiality of patients who only provide information on
responsible family consent
10. Patient-related information can be issued by the chief treating officer, insurance,
including BPJS.
11. BPJS patients who cannot be issued an SEP, then the payment with general status
12. Patients and families are required to follow the applicable regulations at Sanglah
Hospital.
39. INFORMATION NOTE SHEET
AND INTEGRATED EDUCATION
Information and education records
that have been signed by the
education provider and the family
receiving the education
Code that state the understanding of
the recipient have been sign in the
evaluation column
40. PATIENT TRANSFER NOTES
BETWEEN ROOMS
Records of transfer of
patients between rooms that
have been signed by doctor
in charge of the patient
and paramedics
42. INPATIENT MEDICAL
ASSESSMENT
Medical assessment sheet in the
Inpatient Room which has been
filled out by the resident and signed
by doctor in charge of the patient +
there is a doctor in charge of the
patient’s wet stamp
INPATIENT MEDICAL ASSESSMENT
43. CHILD NUTRITIONAL ASSESSMENT
NUTRITIONAL ASSESSMENT
Nutritional assessment according to the
patient’s current condition, have already
been signed by supervisor, resident,
nutritionist, nurse and patient’s parent.
48. ASSESSMENT OF PPA (CARE PROFESSIONALS)
PPA (CARE PROFESSIONAL) has filled in patient care at SIMARS every shift
49. ASSESSMENT OF PPA (CARE PROFESSIONALS)
PPA (CARE PROFESSIONAL) has filled in patient care at SIMARS every shift
50. ASSESSMENT OF PPA (CARE PROFESSIONALS)
PPA (CARE PROFESSIONAL) has filled in patient care at SIMARS every shift
51. sumber : rekomendasi standar penggunaan APD untuk penanganan COVID 19 di
Indonesia (gugus tugas percepatan penanganan COVID 19)
STANDARD USE OF
PERSONAL
PROTECTIVE
EQUIPMENT
52. SELF EVALUATION
No Score Point
Suitability Follow up
improvement
PMKP rule Findings
1 There are some
health workers
who do not use wet
stamp on their
signature
Name in the signature
column should be stamped
using a wet stamp
There are still doctors,
nurse, and admission staff
who do not use wet stamp
in the name column of the
signature
Reminding the health
workers to use wet
stamp in the name
for the signature
2 There are
abbreviations in
integrated notes
that are not in
accordance with
the Prof Dr. I. G. N.
G Ngoerah General
Hospital’s
abbreviation list
Abbreviations in integrated
notes must in accordance to
abbreviation list in Prof Dr.
I. G. N. G Ngoerah General
Hospital
Abbreviation words in
integrated notes was not
in accordance to the
abbreviations list in Prof
Dr. I. G. N. G Ngoerah
General Hospital (ex: DL)
Remind the resident
to write in full words
or phrase for words
that are not written
in Prof Dr. I. G. N. G
Ngoerah General
Hospital’s
abbreviations list
55. LAST MORNING REPORT EVALUATION
QUALITY IMPROVEMENT AND PATIENT
SAFETY
HEMATOONCOLOGY DIVISION
AUGUST 24th, 2022
56. Report of
LAST MORNING REPORT
EVALUATION QUALITY IMPROVEMENT
AND PATIENT SAFETY
Hemato-oncology Division August 24th ,
2022 signed by Head of Maternal and
Child Inpatient Installation and
Moderator
