Professional Documents
Culture Documents
PROGRAM PMKP
RSUD KARAWANG
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PEMILIHAN PRIORITAS
PROGRAM PMKP
(PENINGKATAN MUTU & KESELAMATAN
PASIEN)
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Daftar Isi
DOKUMENTASI
PEMILIHAN PRIORITAS PROGRAM PMKP
Halaman
Daftar isi ................................................................................. i
Materi bahan pemilihan prioritas program PMKP .................. 1
Indikator area klinis ........................................................... 1
Indikator area manajerial .................................................. 3
Indikator sasaran keselamatan pasien ............................. 4
Indikator Joint Commission International Library .............. 4
Notulen rapat pemilihan prioritas program PMKP ................. 8
Waktu ................................................................................ 8
Jumlah peserta yang diundang ........................................ 8
Jumlah peserta yang hadir ............................................... 8
Materi pembahasan .......................................................... 8
Pembahasan ..................................................................... 8
Kesimpulan ....................................................................... 14
Lampiran ...............................................................................
Undangan pemilihan prioritas program PMKP ................. 16
Daftar undangan peserta rapat ......................................... 17
Daftar hadir peserta undangan rapat ................................ 19
Susunan acara ................................................................. 23
Dokumentasi Gambar ....................................................... 24
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MATERI
BAHAN PEMILIHAN PRIORITAS
PROGRAM PMKP
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Materi Bahan Pemilihan Prioritas Program
Peningkatan Mutu dan Keselamatan Pasien (PMKP)
1. Asesmen Pasien
a. Asesmen awal medis lengkap dalam 24 jam pada pasien RI
b. Asesmen awal keperawatan lengkap dalam 24 jam pada pasien RI
c. Asesmen medis pasien bedah sebelum operasi
d. Asesmen medis anestesi sebelum operasi
e. Pelaksanaan skrining nutrisional
f. Asesmen nyeri pada pasien rawat inap
g. Asesmen risiko jatuh pada pasien rawat inap
h. Pre visit anestesi
i. Pasien stroke yang dilakukan assesmen rehabilitasi medis (International
Library)
j. Asesmen awal pasien emergency
2. Pelayanan Laboratorium
a. Waktu tunggu hasil pelayanan laboratorium
b. Pelaksana ekspertisi
c. Tidak adanya kesalahan pemberian hasil pemeriksa laboratorium
d. Waktu tunggu pemeriksaan laboratorium cito
e. Angka keterlambatan penyerahan hasil pemeriksaan
f. Angka kerusakan sampel darah
g. Angka kesalahan pengambilan sampel
h. Angka kesalahan pasien
i. Pelaporan nilai kritis laboratorium
3. Pelayanan Radiologi dan Diagnostic Imagin
a. Waktu Tunggu Hasil Pelayanan Thorax Foto
b. Pelaksana Ekspertisi
c. Kejadian Kegagalan Pelayanan Rontgen
d. Waktu tunggu pemeriksaan Radiologi cito
e. Angka pemeriksaan ulang
f. Angka penolakan expertise
g. Angka keterlambatan penyerahan hasil
h. Angka kesalahan posisi pemeriksaan
i. Angka reaksi obat kontras
j. Penyampaian hasil radiologis kristis kepada dokter pengirim
k. Respon time pem cito dari IGD
l. Respon time USG cito dari IGD non obsgyn
m. Respon time thorax konvensional
4. Prosedur Bedah
a. Waktu tunggu operasi elektif
b. Kejadian Kematian di meja operasi
c. Tidak adanya kejadian operasi salah sisi
d. Tidak adanya kejadian opersi salah orang
e. Tidak adanya kejadian salah tindakan pada operasi
f. Tidak adanya kejadian tertinggalnya benda asing/lain pada tubuh pasien
setelah operasi
g. Angka penundaan operasi
h. Angka keterlambatan dimulainya operasi
i. Angka infeksi luka/daerah operasi
j. Angka ketidak lengkapan informed concent
k. Angka ketidak lengkapan laporan operasi
l. Angka ketidak lengkapan laporan anestesi
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m. Kepatuhan melaksanakan proses time out pada pasien pre operasi
n. Ketidaksesuaian Diagnosis pra dan pasca bedah
o. Marking
5. Penggunaan Antibiotika dan Obat Lainnya
a. Operasi bersih tanpa pemberian profilaxis antibiotik
b. Penulisan resep sesuai formularium
c. Penggunaan antibiotika di ICU sesuai dng hasil resistensi test
d. Pemberian aspirin pada pasien AMI (IIL)
e. Patients with ischemic stroke prescribed antithrombotic therapy at discharge
(IIL)
f. Patients with atrial fibrillation/flutter receiving anticoagulation therapy (IIL)
g. Pediatric asthma patients who received systemic corticosteroids during
hospitalization
h. Patients who received VTE (Venous thrombo embolism) prophylaxis (or
reasons of why this was not done) on the day of or day after hospital
admission or surgery
i. ICU patients who received VTE prophylaxis (or reasons of why this was not
done) on the day of or day after hospital admission or surgery
6. Kesalahan Medikasi (Medication Error) & KNC
a. Ketepatan waktu pemberian antibiotika
b. Ketepatan waktu pemberian injectie antibiotik pada pasien rawat inap.
c. Kejadian Nyaris Cedera Peresepan Obat
d. Kesalahan dan Kejadian Nyaris Cedera Medikasi, Pencegahan Adverse
Drug Event
7. Penggunaan Anestesi dan Sedasi
a. Kelengkapan asesmen pre anestesia
b. Pasien paska pembiusan di transfer dari recorvery room IBS ke ruang
rawat inap sesuai dengan aldrette score
c. Efek samping anestesi pada pasien SC
d. Efek samping sedasi pada pasien endoscopy
e. Komplikasi anastesi karena overdosis,
f. Reaksi anastesi,
g. Salah penempatan endotracheal tube.
8. Penggunaan Darah dan Produk Darah
a. Angka keterlambatan penyediaan darah untuk operasi elektif
b. Angka kesalahan golongan darah
c. Angka kesalahan jenis darah
d. Angka reaksi transfusi darah
e. Angka perbedaan hasil skrining
f. Efektifitas penggunaan darah
g. Kebutuhan darah bagi setiap pelayanan tranfusi
h. Kejadian reaksi tranfusi
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Area manajerial
1. Pengadaan rutin alkes dan obat penting untuk memenuhi kebutuhan pasien;
a. Ketersediaan obat dan alkes emergency di ruang resisutasi IGD
b. Ketersedian obat di RS
c. Ketersediaan obat kemoterapi di RS
2. Pelaporan aktivitas yang diwajibkan oleh peraturan perundang - undangan;
a. Ketepatan waktu penyampaian keuangan sesuai Pedoman Akutansi RS
(PARS)
b. Ketepatan waktu laporan insiden keselamatan pasien
c. Ketepatan waktu laporan dari unit kerja
d. Ketepatan waktu laporan RS (RL)
e. Kelengkapan laporan HIV
f. Laporan KPRS paling lambat 2 x 14 jam
3. Manajemen risiko;
a. Kejadian tertusuk limbah benda tajam infeksius
b. Kejadian tertusuk jarum suntik
c. Kejadian pasien pulang APS
d. Dilakukan FMEA setahun sekali
e. Pengadaan Barang beracun berbahaya (B-3) yang dilengkapi MSDS
(Material Safety Data Sheet)
4. Manajemen penggunaan sumber daya;
a. Utilisasi Ct-Scan
b. Utilisasi ruang VIP
c. Utilisasi USG Dopler 3 Dimensi
d. Utilisasi C-ARM
e. Utilisasi Ploroscopy
f. Utilisasi peralatan kedokteran canggih
5. Harapan dan kepuasan pasien dan keluarga;
a. Tingkat kepuasan pasien RJ, IGD, RI
b. Survei kepuasan pasien menggunakan Index Kepuasan Masyarakat
(IKM)
c. Prosentasi pasien yang mengisi formulir angket pasien
d. Survei kepuasaan pasien dalam satu bulan sekali
6. Harapan dan kepuasan staf;
a. Tingkat kepuasan karyawan
b. Tingkat kepuasan dokter
c. Tingkat kepuasan perawat
7. Demografi pasien dan diagnosa klinis
a. Laporan 10 besar penyakit (demografi pasien)
b. Demografi pasien dengan diagnosis klinik DHF
8. Manajemen keuangan
a. Cost recovery rate
b. Current Ratio
c. Return of invesment (ROI)
9. Pencegahan dan pengendalian dari kejadian yang dapat menimbulkan masalah
bagi keselamatan pasein, keluarga pasien dan staf
a. Edukasi hand hygiene
b. Ketaatan cuci tangan penunjang
c. Ketaatan penggunaan Alat Pelindung Diri (APD)
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Sasaran Keselamatan Pasien
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c. Adult Smoking Cessation Advice/Counseling
Adult smoking(cigarettes) cessation advice/counseling given to heart
failure patients
3. Stroke (STK)
a. Discharged on Antithrombotic Therapy
Ischemic stroke patients prescribed antithrombotic therapy at hospital
discharge
b. Anticoagulation Therapy for Atrial Fibrillation/Flutter
Ischemic stroke patients with atrial fibrillation/flutter who are
prescribed anticoagulation therapy at hospital discharge
c. Stroke Education
Ischemic or hemorrhagic stroke patients or their caregivers who were
given educational material addressing ALL of the following: Activation
of emergency medical system (if available in region), need for follow-
up after discharge, medications prescribed at discharge, risk factors
for stroke, and warning signs and symptoms of stroke.
d. Assessed for Rehabilitation
Ischemic or hemorrhagic stroke patients who were assessed for or
received rehabilitation services.
4. Childrens Asthma Care (CAC)
a. Relievers for Inpatient Asthma
Use of relievers in pediatric patients admitted for inpatient treatment of
asthma
b. Systemic Corticosteroids for Inpatient Asthma
Use of systemic corticosteroids in pediatric patients admitted for
impatient treatment of asthma
5. Hospital-Based Inpatient Psychiatric Service (HBIPS)
a. Hours of physical restraint use
The total number of hours that all patients admitted to a hospital-
based inpatient psychiatric setting were maintained in physical
restraint
b. Hours of seclusion use
The total number of hours that all patients admitted to a hospital-
based inpatient psychiatric setting were held in seclusion.
6. Nursing-Sensitive Care (NSC)
a. Pressure Ulcer Prevalence (HospitalAcquired)
Patients that have hospital-acquired (nosocomial) category/stage II or
greater pressure ulcer(s) on the day of the prevalence study
b. Patient Falls
All documented falls with or without injury, experienced by patients in
a calendar month.
c. Falls with Injury
All documented falls by a patient with an injury level of minor (2) or
greater.
7. Perinatal Care (PC)
a. Elective Delivery
Patients with elective vaginal deliveries or elective cesarean sections
at >= 37 and < 39 weeks of gestation completed
b. Cesarean Section
Nulliparous women with a term, singleton baby in a vertex position
delivered by cesarean section
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c. Exclusive Breast Feeding
Exclusive breast milk feeding during the newborn's entire
hospitalization
8. Pneumonia (PN)
a. Pneumococcal Vaccination
Pneumonia patients, aged 65 and older, who were screened for
pneumococcal vaccine status and were administered the vaccine prior
to discharge, if indicated
b. Adult Smoking Cessation Advice/Counseling
Adult smoking cessation advice/counseling given to patients who
smoke cigarettes and who are hospitalized for pneumonia
c. Influenza Vaccination
Pneumonia patients, aged 50 and older, who during the flu season,
were screened for influenza vaccine status and were vaccinated prior
to discharge, if indicated
9. Surgical Care Improvement Project (SCIP)
a. Prophylactic Antibiotic Received Within One Hour Prior to Surgical
Incision Hip Arthroplasty
Surgical patients with prophylactic antibiotics initiated within one hour
prior to surgical incision. Patients who received Vancomycin or a
Fluroquinolone for prophylactic antibiotics should have the antibiotics
initiated within two hours prior to surgical incision. Due to the longer
infusion time required for Vancomycin and Fluroquinolone, it is
acceptable to start these antibiotics within two hours prior to incision
time
b. Prophylactic Antibiotic Received Within One Hour Prior to Surgical
Incision-Knee Arthroplasty
Surgical patients with prophylactic antibiotics initiated within one hour
prior to surgical incision. Patients who received Vancomycin or a
Flurooquinolone for prophylactic antibiotics should have the antibiotics
initiated within two hours prior to surgical incision. Due to the longer
infusion time required for Vancomycin and Fluroquinolone, it is
acceptable to start these antibiotics within two hours prior to incision
time.
c. Prophylactic Antibiotic Selection for Surgical Patients-Hip Arthroplasty
Surgical patients who received prophylactic antibiotics consistent with
current Hip Arthroplasty guidelines, Appendix C, Table 3.2,
Prophylactic Antibiotic Regimen Selection for Surgery
d. Prophylactic Antibiotic Selection for Surgical Patients-Knee
Arthroplasty
Surgical patients who received prophylactic antibiotics consistent with
current Knee Arthroplasty guidelines Appendix C, Table 3.2,
Prophylactic Antibiotic Regimen Selection for Surgery
e. Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery
End Time- Hip Arthroplasty
Surgical patients, who had a Hip Arthroplasty, whose prophylactic
antibiotics were discontinued within 24 hours after Anesthesia End
Time
f. Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery
End Time Knee Arthroplasty
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Surgical patients, who had a Knee Arthroplasty, whose prophylactic
antibiotics were discontinued within 24 hours after Anesthesia End
Time
g. Surgery Patients with Recommended Venous Thromboembolism
Prophylaxis Ordered
Surgery patients with recommended Venous Thromboembolism (VTE)
prophylaxis ordered anytime from hospital arrival to 24 hours after
Anesthesia End Time,
h. Surgery Patients Who Received Appropriate Venous
Thromboembolism Prophylaxis Within 24 hours Prior to Surgery to 24
Hours After Surgery
Surgery patients who received appropriate Venous Thromboembolism
(VTE) prophylaxis within 24 hours prior to Anesthesia Start Time to 24
hours after Anesthesia End Time
10. Venous Thromboembolism (VTE)
a. Venous Thromboembolism Prophylaxis
This measure assesses the number of patients who received VTE
prophylaxis or have documentation why no VTE prophylaxis was
given the day of or the day after hospital admission or surgery end
date for surgeries that start the day of or the day after hospital
admission.
b. Intensive Care Unit Venous Thromboembolism Prophylaxis
This measure assesses the number of patients who received VTE
prophylaxis or have documentation why no VTE prophylaxis was
given the day of or the day after the initial admission (or transfer) to
the Intensive Care Unit (ICU) or surgery end date for surgeries that
start the day of or the day after ICU admission (or transfer).
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NOTULEN RAPAT
PEMILIHAN PRIORITAS
PROGRAM PMKP
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PEMERINTAH KABUPATEN KARAWANG
BADAN LAYANAN UMUM DAERAH
RUMAH SAKIT UMUM DAERAH KELAS B NON PENDIDIKAN
JL. Galuh Mas Raya No. 1 Sukaharja Telukjambe Timur
Telp (0267) 640444, 640555 Fax (0267) 640666
KARAWANG
Notulen Rapat
Pemilihan Prioritas Program Peningkatan Mutu
dan Keselamatan Pasien (PMKP)
Hari : Sabtu
Tanggal : 12 Maret 2016
Jam : 09.00 12.00
Tempat : Swiss Bellin Hotel Karawang
Peserta yang diundang : 133 Orang
Peserta yang hadir : 80 Orang (60,15%)
Materi Pembahasan :
Pemilihan Prioritas Program PMKP
1. Menetapkan Indikator kunci/prioritas di 10 area klinik
2. Menetapkan 5 Indikator klinis sesuai Joint Commission International Library
3. Menetapkan Indikator kunci/prioritas di 9 area manajemen
4. Menetapkan Indikator kunci/prioritas di sasaran keselamatan pasien (SKP)
Pembahasan :
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2. 5 Indikator Klinis Joint Commission International Library
International
Library of Measure Short
No Measure Description Standar
Measures- Name
Measure Sets
1 Acute Aspirin at Arrival Aspirin received within 24 100%
Myocardial hours of arrival to the
Infarction hospital for patients
(AMI) having an acute
myocardial infarction
(AMI).
2 Stroke (STK) Stroke Education Ischemic or hemorrhagic 100%
stroke patients or their
caregivers who were
given educational material
addressing ALL of the
following: Activation of
emergency medical
system (if available in
region), need for follow-up
after discharge,
medications prescribed at
discharge,
3 Childrens Systemic Use of systemic 100%
Asthma Care Corticosteroids for corticosteroids in pediatric
(CAC) Inpatient Asthma patients admitted for
impatient treatment of
asthma
4 Perinatal Care Exclusive Breast Exclusive breast milk 100%
(PC) Feeding feeding during the
newborn's entire
hospitalization
5 Pneumonia Adult Smoking Adult smoking cessation 100%
(PN) Cessation advice/counseling given to
Advice/Counseling patients who smoke
cigarettes and who are
hospitalized for
pneumonia
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4 Manajemen penggunaan Utilisasi Ct-Scan 100%
sumber daya;
5 Harapan dan kepuasan Survei kepuasan pasien 2 kali / Tahun
pasien dan keluarga; menggunakan Index Kepuasan
Masyarakat (IKM)
6 Harapan dan kepuasan Tingkat kepuasan karyawan 70%
staf;
7 Demografi pasien dan Demografi pasien dengan 100%
diagnosa klinis diagnosis klinik DHF
8 Manajemen keuangan Cost recovery rate 80%
9 Pencegahan dan Edukasi hand hygiene 100%
pengendalian dari
kejadian yang dapat
menimbulkan masalah
bagi keselamatan pasien,
keluarga pasien dan staf
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Penetapan Pelayanan Prioritas
Keterangan:
Pelayanan prioritas perbaikan : Childrens Asthma Care (CAC), Penggunaan kortikosteroid sistemik pada pengobatan
asthma bagi pasien-pasien anak yang menjalani rawat inap (Use of systemic corticosteroids in pediatric patients admitted for
impatient treatment of asthma)
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Penetapan Area Prioritas
N B S N B S N B S
Keterangan:
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Kriteria Pemilihan Indikator Utama
Score
No Definisi 1 2 3 4 5
Min Max
1 High Risk ( Indikator yang Tidak Timbul Timbul Timbul Timbul Timbul Resiko
dipilih merupakan kondisi 1 5 Resiko Resiko Resiko Resiko Sangat Besar
berresiko pada pasien) Kecil Sedang Besar
2 High Volume ( Indikator Sangat Jarang (2-5 Dpt terjadi (beberapa Sering sekali
yang dipilih merupakan 1 5 Jarang (> 5 Thn/kali) dlm 1-2 thn kali/thn) (terjadidlm
yang sering terjadi) Thn) minggu/bulan)
3 High Cost ( Indikator yang Tidak timbul Timbul Timbul Timbul Timbul
dipilih merupakan kondisi kerugian kerugian kerugian kerugian kerugian
1 5
yang menimbulkan keuangan keuangan keuangan keuangan keuangan
kerugian keuangan) kecil sedang besar sangat besar
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Kesimpulan :
1 Aspirin at Arrival
2 Stroke Education
3 Systemic Corticosteroids for Inpatient Asthma
4 Exclusive Breast Feeding
5 Adult Smoking Cessation Advice/Counseling
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Pelayanan prioritas perbaikan : Childrens Asthma Care (CAC), Penggunaan kortikosteroid
sistemik pada pengobatan asthma bagi pasien-pasien anak yang menjalani rawat inap (Use
of systemic corticosteroids in pediatric patients admitted for impatient treatment of asthma)
Pemimpin Rapat
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LAMPIRAN
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UNDANGAN
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DAFTAR HADIR
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PEMERINTAH KABUPATEN KARAWANG
BADAN LAYANAN UMUM DAERAH
RUMAH SAKIT UMUM DAERAH KELAS B NON PENDIDIKAN
JL. Galuh Mas Raya No. 1 Sukaharja Telukjambe Timur
Telp (0267) 640444, 640555 Fax (0267) 640666
KARAWANG
Susunan Acara
PEMILIHAN PRIORITAS PROGRAM
PENINGKATAN MUTU DAN KESELAMATAN PASIEN (PMKP) RSUD KARAWANG
Sabtu, 12 Maret 2016
Swiss Bellinn Hotel Karawang
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DOKUMENTASI GAMBAR
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Rapat pembahasan pemilihan prioritas program PMKP Sabtu, 12 Maret 2016 di
Swiss Bellinn Hotel Karawang dibuka oleh Direktur RSUD Karawang dr. H. Asep
Hidayat Lukman, MM
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Salah satu sudut peserta yang hadir
saat rapat pembahasan pemilihan prioritas program PMKP Sabtu, 12 Maret 2016 di
Swiss Bellinn Hotel Karawang dari kiri, Heru Pamuji, Amd.PK (Rekam Medis),
Dadang Sukardi, Amd.PK (Rekam Medis), Ahmad Rofiudin, Amd.PK (Rekam
Medis), Kurniasih, S.Kep (Bidang Keperawatan), Ani Muthia, SKM, MARS (Bidang
Perencanaan)
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Direktur RSUD Karawang, dr. H. Asep Hidayat Lukman, MM didampingi dr. Irwin,
Sp.PD Ketua Pokja PMKP saat pembukaan rapat pembahasan pemilihan prioritas
program PMKP Sabtu, 12 Maret 2016 di Swiss Bellinn Hotel Karawang.
dr. Irwin, Sp.PD Ketua Pokja PMKP saat presentasi rapat pembahasan pemilihan
prioritas program PMKP Sabtu, 12 Maret 2016 di Swiss Bellinn Hotel Karawang
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dr. Ade Nurkacan, Sp.AN dan dr. Irwin, Sp.PD Ketua Pokja PMKP saat berdiskusi
pada rapat pembahasan pemilihan prioritas program PMKP Sabtu, 12 Maret 2016 di
Swiss Bellinn Hotel Karawang
Pose bersama saat setelah acara rapat pembahasan pemilihan prioritas program
PMKP Sabtu, 12 Maret 2016 di Swiss Bellinn Hotel Karawang. Dari kiri dr. Endang
Elisawaty, Sp.S, dr Achmad Rizky Herda, Sp.U, dr. Irwin, Sp.PD, dr. Irwan, dr. H.
Asep Hidayat Lukman, MM (Direktur RSUD Karawang), dr. Ade Nurkacan, Sp.AN,
Sutarman, S.Kep, Sri Endah, S.Kep, Ners (belakang) dan dr. David A, Sp.OG.
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