Knc, Ktc, Ktd.docx

FORM LAPORAN INTERNAL INSIDEN KESELAMATAN PASIEN (KNC,KTC,KTD DAN KEJADIAN SENTINEL) I.

DATA PASIEN Nama : ........................................ NO CM : ....................................... UMUR : ........................................ Jenis Kelamin : Laki – laki Perempuan

II.

RINCIAN KEJADIAN 1. Tanggal dan Waktu Insiden Tanggal : ................................. Jam ...................... 2. Insiden : ............................................................... 3. Kronologi Insiden ................................................................................................................................. .................................................................................................................................... ................................................................................................................................... .................................................................................................................................... ................................................................................................................................... ...................................................................................................................................... ....................................................................................................................................... ..................................................................................................................................... 4. Jenis Insiden : Kejadian Nyaris Cedera / KNC Kejadian Tidak diharapkan / KTD Kejadian Tidak Cedera / KTC

Kejadian Sentinel

5. Orang yang Melaporkan Insiden Karyawan : Dokter / Perawat / Petugas Lainnya Keluarga / pendamping pasien Pasien Pengunjung Lain – lain 6. Insiden terjadi pada : Pasien Lain – lain 7. Tempat Insiden Lokasi Kejadian .................................................................................................................... .............................................................................................................................................

8. Akibat Insiden Terhadap Pasien : Kematian Cedera Ringan Cedera Berat

Tidak ada Cedera

Cedera Sedang 9. Tindakan yang dilakukan segera setelah kejadian dan hasilnya : ................................................................................................................................................... ................................................................................................................................................... .................................................................................................................................................. 10. Tindakan dilakukan oleh : Dokter Perawat Petugas Lainnya

Tgl Lapor

:

Tgl terima

:

Pembuat Laporan

:

Penerima Laporan

:

paraf

:

Paraf

: