10 Langkah Ke 7 Cegah Cedera Melalui Implementasi Keselamatan Pasien DR Arjaty PDF

LANGKAH 7
Dr Arjaty W Daud MARS
1.
2.
3.
4.
LATAR BELAKANG PERLUNYA REDESAIN

PROSES DI PELAYANAN KESEHATAN
STRATEGI REDUKSI RISIKO
IDENTIFIKASI PROSES YG RISIKO TINGGI
REDISAIN PROSES :
- FMEA
- AMKD / HFMEA
Arjaty/ IMRK/FMEA/2008
Historical Perspective
Hingga
saat ini,
pencegahan
Until recently,
error
preventionkesalahan
has not
medis
menjadi
fokus
utama bidang
been abelum
primary
focus of
medicine
kedokteran
z System/process defects are identified by
adverse events or dealt with silently by
health care personnel
z Sebagian besar sistem pelayanan
healthtidak
caredidesain
delivery untuk
systems
are not
z Most
kesehatan
mencegah
designed
to prevent
and / or compensate
atau mencegah
/ mengatasi
error
for errors
z
z
JCAHO Standard LD 5.2

(efective July 2001)
Identify
anddan
prioritize
high risk
processes
Identifikasi
proritaskan
PROSES
Annually
select at least
one high risk
YANG
BERISIKO
TINGGI
process
z Identifikasi POTENSI MODUS
Identify potential
z KEGAGALAN
failure modes
each
failure
mode, identify
possible
z
Setiap
modus
kegagalan,
IDENTIFIKASI
z For
effects
DAMPAK YANG MUNGKIN TERJADI
thesetiap
most dampak
critical effects,
conduct a root
z
Untuk
yang kritis,
z For
cause
analysis
LAKUKAN
ANALISIS AKAR MASALAH.
z
z
z
JCAHO Standard LD 5.2

(efective July 2001)
REDISAIN
the
zzRedesign
PROSES
untuk the risk of that
process
to minimize
failure
mode or to protect
its
meminimalisasi
risiko patients
modus from
kegagalan
effects
atau mencegah dampaknya pada pasien
z Test and implement the redesigned process
z UJI COBA DAN IMPLEMENTASI
z Identify and implement measures of
REDISAIN PROSES
effectiveness
z IDENTIFIKASI DAN NILAI EFEKTIVITAS
z Implement a strategy for maintaining the
IMPLEMENTASI
effectiveness
of the redesigned process over
proses redisain. STRATEGI untuk
IMPLEMENTASIKAN
ztimeatau
efektivitas maintanance
6
Advanced Patient safety in US since 1999, NPCS,
August 2004, www,patientsafety.gov
RISK REDUCTION STRATEGIES DIFFICULTY &

LONG TERM EFFECTIVENESS
Types of actions
Degree of
difficulty
Long term
effectiveness
Easy
Low
2.
Punitive
Retraining / counseling
3.
Process redesign
4.
Paper vs practice
Technical system enhance
Culture change
1.
5.
6.
Difficult
High
7
Definition of a Process
A goal-directed interrelated series of
events, activities, actions, mechanisms,
or steps that transform inputs into
outputs
(CAMH Glossary)
INPUT
PROSES
OUTPUT

Identifikasi risiko dgn bertanya 3 pertanyaan
dasar :
1. Apa prosesnya ?
2. Dimana risk points / cause?
3. Apa yg dapat dimitigate pada
dampak risk points ?

RISK
POINTS /
COMMON CAUSES
RENCANA
REDUKSI RISIKO
Design Proses u/
Meminimalkan
risiko
Kegagalan terjadi
Pada pasien
Design Proses u/
Meminimalkan
risiko
kegagalan
Design Proses u/
Mengurangi
Dampak
Kegagalan terjadi
10
pada pasien
MEMILIH PROSES
z
High Risk processes

z Identified
in the literature
z Identified by JCAHO
z Identified through safety alerts
New or redefined process

z Staff recommendations
z
11
IDENTIFYING RISK PRONE SYSTEM

Variable input
z Complex systems
z Non standardized systems
z Tightly coupled systems
z Systems with tight time constraints
z Systems with hierarchical
z
12
REDISAIN PROSES
FMEA
z
z
z
z
z
z
z
Variable input
Complex
Nonstandarized
Tightly Coupled
Dependent on human
intervention
Time constraints
Hierarchical culture
z
z
z
z
z
z
z
z
z
Decreasing variability
Simplify
Standardizing
Loosen coupling of process
Use technology
Optimise Redundancy
Built in fail safe mechanism
Documentation
Establishing a culture of
teamwork
13
Variable input
Pasien
z Penyakit berat
z Penyakit penyerta
z Pernah mendapatkan pengobatan
z Usia
Pemberi Pelayanan
z Tingkat keterampilan
z Cara pendekatan
Proses Pelayanan harus dapat mengakomodasi
variabilitas yang tdk dapat dihindarkan dan tidak dapat
dikontrol ini.
14
Complexitas
z
z
z
z
Pelayanan rumah sakit sangat kompleks

Memerlukan beragam langkah yang sangat
mungkin berhadapan dengan kegagalan
Semakin banyak langkah semakin besar
kemungkinan gagal
Donald Berwick :
1 langkah
-- error 1 %
25 langkah -- error 22%
100 langkah -- error 63%
15
Lack of Standardization
z
Standard - -- proses tidak dapat berjalan

sesuai dengan harapan
Individu yang menjalankan proses harus
melaksanakan langkah langkah yang telah
ditetapkan secara konsisten
Variabilitas individual sangat tinggi -
perlu standard mis : SPO, Parameter, Protokol,
Clinical Pathways dapat membatasi pengaruh
dari variabel yang ada.
16
Heavily dependent on human Intervention

z
z
z
z
z
Ketergantungan yang tinggi akan intervensi

seseorang dalam proses dapat menimbulkan
variasi penyimpangan.
Tidak semua improvisasi bersifat buruk, dikenal
creating safety at the sharp end
Pelayanan kesehatan sangat tergantung pada
intervensi manusia
Petugas harus mampu mengendalikan situasi
yang tidak terduga demi keselamatan pasien
Sangat tergantung pada pendidikan dan pelatihan
yang memadai sesuai dengan tugas & fungsinya
17
Tightly Coupled
z
Perpindahan langkah dari suatu proses sering sangat

ketat, kadang baru disadari terjadi penyimpangan
pada langkah yang telah lanjut.
Keterlambatan dalam suatu langkah akan

mengakibatkan gangguan pada seluruh proses
Kekeliruan dalam suatu langkah akan mengakibatkan

penyimpangan pada langkah berikut ( cascade of
faillure )
Kesalahan biasanya terjadi pada saat perpindahan

langkah atau adanya langkah yang terabaikan
18
Hierarchical culture
z
Suatu proses akan menghadapi risiko kegagalan lebih

tinggi dalam unit kerja dengan budaya hirarki
dibandingkan dengan unit kerja yang budayanya
berorientasi pada team.
Staf enggan berkomunikasi & berkolaborasi satu dengan

yang lain
Perawat enggan bertanya kepada dokter atau petugas

farmasi tentang medikasi, dosis, serta element perawatan
lainnya
Budaya hirarki sering tercipta misalnya dalam menentukan

penggunaan obat, verifikasi lokasi pembedahan oleh tim
bedah.
Tata cara berkomunikasiArjaty/antar

staf dalam proses
IMRK/FMEA/2008
pelayanan kesehatan sangat menentukan hasilnya.
19
Implementing Safety Cultures in Medicine:

What We Learn by Watching Physicians
Timothy J. Hoff, Henry Pohl, Joel Bartfield
Residen di Kamar Bedah : ~ Commission

~ Suasana hierarki tinggi
~ Kesalahan Teknis
Residen di MICU
: ~ Ommission
Suasana hierarki lebih datar
~ Kesalahan Pengambilan
Keputusan
20
What is FMEA ?
z
z
z
Adalah metode perbaikan kinerja dgn

mengidentifikasi dan mencegah potensi kegagalan
sebelum terjadi. Hal tersebut didesain untuk
meningkatkan keselamatan pasien.
Adalah proses proaktif, dimana kesalahan dpt
dicegah & diprediksi.
Mengantisipasi kesalahan akan meminimalkan
dampak buruk
21
FMEA
Whats the point?
Eliminating
Dengan mengeliminasi
or reducing theatau
risk mereduksi
of the failure
modes
canmenghasilkan
result in a
risiko kegagalan
akan
suatu
SAFER YANG
AND MORE
SISTEM
AMANEFFICIENT
DAN LEBIHSYSTEM
EFISIEN
from which BAGI
both you
patients
benefit.
RS and
DANyour
PASIEN
.
22
Failure Mode and Effects Analysis

1. Define failure mode.
what could go wrong?
2. Identify cause of failure.

3. Identify effects of failure
why would the failure

happen?
what would be the
consequences of each
failure?
4. Corrective action.
23
FMEA Terminology
z
Process FMEA - Conduct an FMEA on a

process that is already in place
Design FMEA Conduct an FMEA before

a process is put into place
z Implementing
an electronic medical records or

other automated systems
z Purchasing new equipment
z Redesigning Emergency Room, Operating
Room, Floor, etc.
24
FAILURE MODE AND EFFECTS ANALYSIS

FAILURE (F) : When a system or part of a system
performs in a way that is not
intended or desirable
MODE (M) :
The way or manner in which
something such as a failure can
happen. Failure mode is the
manner in which something can
fail.
EFFECTS (E) : The results or consequences of a
failure mode
Analysis (A) : The detailed examination of the
elements or structure of a process
25
Why should my organization

conduct an FMEA ?
z
z
z
Can prevent errors & near misses protecting

patients from harm.
Can increase the effectiveness & efficiency of
process
Taking a proactive approach to patient safety
also makes good business sense in a health
care environment that is increasingly facing
demands from consumers, regulators & payers
to create culture focused on reducing risk &
increasing accountability
26
Where did FMEA come from ?

FMEA has been around for over 30 years
z Recently gained widespread appeal
outside of safety area
z New to healthcare
z
z Frequently
used reliability & system safety

analysis techniques
z Long industry track record : Aviation,
Nuclear power, Aerospace, Chemical

process industries, Automoive
27
LANGKAH FMEA
1.
2.
3.
4.
5.
6.
7.
8.
Select a high risk process & assemble a team

Diagram the process
Brainstorm potential failure modes & determine their
effects (P X S X D)
Prioritize failure modes
Identify root causes of failure modes (P X S X D)
REDESIGN THE PROCESS
Analyze & test the new process
Implement & monitor the redesigned process
28
Step One
Select a process to evaluate with FMEA
Recruit a multi disciplinary team
Be sure to include everyone

who is involved at any point in the process
Step Two
Have the team meet together to list all the
steps in the process
Number every step in the process and be as
specific as possible
29
Step Three
Have the team list failure modes and effect
z List anything that could go wrong including
minor and rare problems
z Identify all possible causes for each failure mode
For each failure mode, determine the potential effect on the patient
Likelihood of occurrence
Likelihood of detection
Severity
30
31
RATING SYSTEM
(Modified by IMRK)
Rating
Probabilitas
(P)
Severity
(S)
Deteksi
(D)
Remote
Minor effect
Certain to detect
Low likelihood
Moderate effect
High likelihood
Moderate
likelihood
Minor injury
Moderate
likelihood
High likelihood
Major injury
Low likelihood
Certain to
occur
Catastrophic effect
/ terminal injury,
death
Almost certain
not to detect
Risk Priority Number (RPN) / Criticaly Index (CI) = (P x S) x D

32
Step four
Prioritize failure mode
Step five
Have the team list effect of failure mode
For each failure mode, determine the potential cause on the patient
Likelihood of occurrence
Likelihood of detection
Severity
33
Step Six
z
z
z
z
z
z
REDESIGN PROCESS
Determine which failures to work on
Calculate the RISK PRIORITY NUMBER (RPN):
Likelihood x Severity x Detection
Identify the failure modes with the top 10 RPNs
TAKE A DEEP BREATH
Conduct a literature search to gather relevant
information from the professional literature. Do not
reinvent the wheel
Network with colleagues
RECOMMIT TO OUT OF THE BOX THINKING
34
Step Seven
Analyze and test the new process
Use RPNs to plan improvement efforts
z
Failure modes with high RPNs are usually the most

important parts of the process to concentrate
improvement efforts.
The team again completes steps 2 (diagram the
process), step 3 (brainstorm potential failure modes &
determine their effect) and step 4 (prioritize failure
modes) of the FMEA process
Then the team should calculate a new criticality index
(CI) or RPN.
35
Step Eight
Implement & monitor the redesigned
process
z
Design improvements should bring

reduction in the CI / RPN.
Ex: 30 50% reduction ?
36
What is HFMEA ?
Modified by VA NCPS
z
Focus on preventing defects, enhancing safety, increase

positive outcome and increase patient satisfaction
The objective is to look for all ways for process or product

can fail
The famous question : What is could happen? Not What

does happen ?
Hybrid prospective analysis model combines concepts :

FMEA (Failure Mode and Effects Analysis)
HACCP (Hazard Analysis Critical Control Points)
RCA
(Root Cause Analysis)
37
HFMEA Components and Their Origins

Concepts
HFMEA
FMEA
HACCP
RCA
Team membership
Diagramming
process
Failure mode &

causes
Hazard Scoring
Matrix
Severity & Probability

Definitions
Decision Tree
Actions & Outcomes
Responsible person
& management
concurrence
V
V
V
#
V
V
HACCP : Hazard Analysis Critical Control Point
38
TIME LINE AND TEAM ACTIVITIES

Premeeting
Identify Topic and notivy the team (Step 1 & 2)
1st team meeting
Diagram the process, identify subprocess, verify the scope
2rd team meeting
Visit the worksite to observe the process, verify that all process &
subprocess steps are correct (Step 3)
3 rd team meeting
Brainstorming failure modes, assign individual team members to

consult with process users (Step 3)
4rd team meeting
Identify failure modes causes, assign individual team members to

consult with process users for additional input (Step 3)
5th team meeting
Transfer FM & Causes to the HFMEA Worksheet (Step3). Begin the

hazard analysis (Step 4)
Identify corrective actios and assign follow up responsibilities (Step 5)
6th,7th , 8th. team

meeting plus 1
Assign team members to follow up individual charged with taking

corrective action
team meeting plus 2
Refine corrective actions based on feedback
team meeting plus 3
Test the proposed changes
team meeting plus 4
Meet with Top Management to obtain approval for all actions
Postteam meeting
The advisor or his/ her designee follow up until all actions are
completed
39
LANGKAH-LANGKAH
ANALISIS MODUS KEGAGALAN & DAMPAK (AMKD)
(HEALTHCARE FAILURE MODE EFFECT AND ANALYSIS)
(HFMEA)
By : VA NCPS
1. Tetapkan Topik AMKD

2. Bentuk Tim
3. Gambarkan Alur Proses
4. Buat Hazard Analysis
5. Tindakan dan Pengukuran Outcome
Step 1
z
Define the Scope of HFMEA along with a

clear definition of the process to be
studied
Step 2
z
Multidisiplinary team with Subject matter

expert(s) plus advisor
41
Step 3
z
z
z
z
Develop and verify the flow Diagram (this is a

process vs chronological diagram)
Consecutively number each process step
identified in the process flow diagram
If the process is complex identify the area of the
process to focus on (manageable bite)
Identify all sub processes under each block of
this flow diagram. Consecutively letter these sub
steps
Create a flow diagram composed of the sub
processes
42
Step 4
List Failure modes
z Determine Severity & Probability
z Use the Decision tree
z List all Failure mode causes
z
43
Step 5
z
z
z
z
z
Decide to Eliminate Control or Accept the

failure mode cause
Describe an action for each failure mode cause
that will eliminate or control it.
Identify outcome measures that will be used to
analyze and test the re-designed process
Identify a single, responsible individual by title to
complete the recommended action
Indicate whether top management has
concurred with the recommended actions
44
FMEA vs HFMEA vs HFMECA

FMEA
Original
HFMEA
By : VA NCPS
HFMECA
By IMRK
Select a high risk process &

assemble a team
Define the HFMEA

Topic
Select a high risk process &

assemble a team
Diagram the process
Assemble the Team
Diagram the process
Brainstorm potential failure

modes & determine their effects
(P X S X D)
Graphically describe
the Process
Brainstorm potential failure

modes
(P X S) x K X D, Bands
Conduct a Hazard
Analysis
Identify root causes of failure

modes
(P X S X D)
Actions & Outcome

Measures
Identify root causes of failure

modes
(P X S) x K X D, Bands
Implement & monitor the

redesigned process
CALCULATE TOTAL RPN

Implement & monitor the

redesigned process
45
RATING SYSTEM HFMECA

(Modified by IMRK)
Rating
Probabilitas
(P)
Severity
(S)
Kontrol
(K)
Deteksi
(D)
Remote
Minor effect
Easy
Certain to detect
Low likelihood
Moderate effect
Mpderate
Easy
High likelihood
Moderate
likelihood
Minor injury
Moderate
difficult
Moderate
likelihood
High likelihood
Major injury
Difficult
Low likelihood
Certain to
occur
Catastrophic effect
/ terminal injury,
death
Almost certain
not to detect
Risk Priority Number (RPN) / Criticaly Index (CI) = (P x S) x K x D

46
47
LANGKAH 1 : PILIH PROSES YANG BERISIKO TINGGI

Pilih Proses berisiko tinggi yang akan dianalisa.
Judul Proses :
__________________________________________________________________________
_________________________________________________________
_________________________________________________________
LANGKAH 2 : BENTUK TIM
Ketua
:
____________________________________________________________
Anggota
1. _______________
4.
________________________________________
2. _______________
5.
________________________________________
3. _______________
6.
________________________________________
Notulen? _________________________________________
Apakah semua Unit yang terkait dalam Proses sudah terwakili ?
YA / TIDAK
Tanggal dimulai ____________________ Tanggal selesai ___________________
48
Contoh kasus 1
49
50
51
52
53
ANALISIS
DAMPA
K
Pasien
MODERAT
2
MAYOR
3
Kegagalan yang tidak

mengganggu Proses
pelayanan kepada
Pasien
Kegagalan dapat
mempengaruhi proses
dan menimbulkan
kerugian ringan
Kegagalan menyebabkan
kerugian berat
Kegagalan menyebabkan
kerugian besar
zTidak ada cedera,

zTidak ada
zCedera ringan
zAda Perpanjangan
zCedera
luas / berat
zPerpanjangan hari
rawat
lebih lama (+> 1 bln)
zBerkurangnya fungsi
permanen organ tubuh
(sensorik / motorik /
psikcologik / intelektual)
Cedera luas / berat

z Perlu dirawat
z Terjadi pada 4 -6
orang
pengunjung
zKematian
zCedera
zKematian
MINOR
1
perpanjangan
hari rawat
Pengunju
ng
Staf:
Fasilitas
Kes
HAZARD LEVEL DAMPAK
hari rawat
zTidak ada cedera

zTidak ada penanganan
z Cedera ringan
z Ada Penanganan
zTerjadi pada 1-2
pengunjung
ringan
z Terjadi pada 2 -4
pengunjung
zTidak ada cedera

zTidak ada penanganan
zCedera ringan
z Ada Penanganan /
zTerjadi pada 1-2 staf

zTidak ada kerugian
waktu / keckerja
Tindakan
z Kehilangan waktu /
kec kerja : 2-4 staf
Kerugian < 1 000,,000

atau tanpa menimbulkan
dampak terhadap pasien
Kerugian
Kerugian
10,000,000 - 50,000,000
1,000,000 - Arjaty/ IMRK/FMEA/2008
10,000,000
org
luas / berat
z Perlu dirawat
zKehilangan waktu /
kecelakaan kerja pada
4-6 staf
KATASTROPIK
4
Kematian
z Kehilangan fungsi tubuh
secara permanent (sensorik,
motorik, psikologik atau
intelektual) mis :
z Operasi pada bagian atau
pada pasien yang salah,
z Tertukarnya bayi
zTerjadi
pada > 6 orang

pengunjung
zPerawatan
> 6 staf
Kerugian > 50,000,000

54
ANALISIS HAZARD LEVEL PROBABILITAS

LEVEL
DESKRIPSI
CONTOH
Hampir sering muncul dalam waktu yang
relative singkat (mungkin terjadi
beberapa kali dalam 1 tahun)
Sering (Frequent)
Kadang-kadang
(Occasional)
Kemungkinan akan muncul

(dapat terjadi bebearapa kali dalam 1
sampai 2 tahun)
Jarang (Uncommon)
Kemungkinan akan muncul

(dapat terjadi dalam >2 sampai 5 tahun)
Hampir Tidak Pernah Jarang sekali terjadi (dapat terjadi dalam

(Remote)
> 5 sampai 30 tahun)
55
HAZARD SCORE
TINGKAT BAHAYA
KATASTROPIK
4
MAYOR MODERAT
3
2
MINOR
1
SERING
4
16
12
KADANG
3
12
JARANG
2
HAMPIR TIDAK
PERNAH
1
56
Decision Tree
Gunakan Decision Tree utk menentukan apakah modus perlu tindakan lanjut
diProceed..
Does this hazard involve a
sufficient likelihood of
occurrence and severity to
warrant that it be
controlled?
(Hazard score of 8 or
higher)
YES
NO
Is this a single point weakness in

the process? (Criticality failure
results in a system failure?)
CRITICALY
YES
Does an effective control measure
already exist for the identified hazard?
CONTROL
NO
Is this hazard so obvious and readily
apparent that a control measure is not
warranted?
DETECTABILITY
NO
NO
YES
STOP
YES
Proceed to
Potential
Causes for
this failure
mode
Do not proceed
to find potential
causes for this
failure mode
57
Contoh kasus 2
PROSES KEGIATAN PAGI HARI MENUJU TEMPAT KERJA
58
59
60
61
62
63
64
65
LEMBAR AMKD ( FORM HFMEA )

AMKD Langkah 4 - Analisis Hazard
HFMEA : Healthcare Failure Mode Effect and Analysis
Eliminate
Tindakan /
Alasan
untuk
mengakhiri
Purchased
new clock
Purc
hase
d by
cert
ain
date
.....
Manajemen Tim
Occa
sional
Tipe
Tindakan
(Kontrol,
Kontrol,
terima,
terima,
Eliminasi)
Eliminasi)
Yang Bertanggung
Jawab
major
Proses ?
Apakah mudah
didteksi ?
occas
ional
Apakah ada
kontrol/pengen
dalian?
major
Poin Tunggal
Kelemahan ?
Missed
snooze button
Nilai Hazard
Turn off alarm
Probabilitas
POTENSI
PENYEBAB
Analisis Pohon Keputusan
Ukuran Outcome
SKORING
Kegawatan
MODUS
Kegagalan :
Evaluasi awal
modus
kegagalan
sebelum
AMKD Langkah 5 - Identifikasi Tindakan & Outcome
Mr..
Yes
66
AMKD / HFMEA
Proses lama
yg high risk
Alur
Proses
Potential Cause
Failure
Mode
Efek /
Dampak
Decision
Tree
HS
K
K
Tindakan
K
E
D
T
Desain
Proses baru
Hazard
Score
Kritis
Kontrol
Deteksi
Kontrol
Eliminasi
Terima
67
AMKDP / HFMECA
Prioritas
risiko
Total RPN
PROSES
LAMA
Failure
Redisign
Proses
Mode,
Dampak,
Penyebab
Analisis &
Uji Proses Baru
Total RPN
PROSES
BARU
Implementasi
PROSES BARU
Failure
Mode,
Dampak,
Penyebab
Total RPN
30-50%?
68
KESIMPULAN
Building a safe healthcare system
A
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P
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M
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W
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I
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N
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S
G
K
U
L
E
A
R
N
I
N
G
S
E
V
E
R
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T
Y
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10 Langkah Ke 7 Cegah Cedera Melalui Implementasi Keselamatan Pasien DR Arjaty PDF

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LANGKAH 7

Dr Arjaty W Daud MARS

LATAR BELAKANG PERLUNYA REDESAIN

JCAHO Standard LD 5.2

JCAHO Standard LD 5.2

RISK REDUCTION STRATEGIES DIFFICULTY &

STRATEGI REDUKSI RISIKO

STRATEGI REDUKSI RISIKO

High Risk processes

New or redefined process

IDENTIFYING RISK PRONE SYSTEM

Pelayanan rumah sakit sangat kompleks

Standard - -- proses tidak dapat berjalan

Heavily dependent on human Intervention

Ketergantungan yang tinggi akan intervensi

Perpindahan langkah dari suatu proses sering sangat

Keterlambatan dalam suatu langkah akan

Kekeliruan dalam suatu langkah akan mengakibatkan

Kesalahan biasanya terjadi pada saat perpindahan

Suatu proses akan menghadapi risiko kegagalan lebih

Staf enggan berkomunikasi & berkolaborasi satu dengan

Perawat enggan bertanya kepada dokter atau petugas

Budaya hirarki sering tercipta misalnya dalam menentukan

Tata cara berkomunikasiArjaty/antar

Implementing Safety Cultures in Medicine:

Residen di Kamar Bedah : ~ Commission

Adalah metode perbaikan kinerja dgn

Failure Mode and Effects Analysis

2. Identify cause of failure.

why would the failure

Process FMEA - Conduct an FMEA on a

Design FMEA Conduct an FMEA before

an electronic medical records or

FAILURE MODE AND EFFECTS ANALYSIS

Why should my organization

Can prevent errors & near misses protecting

Where did FMEA come from ?

used reliability & system safety

Nuclear power, Aerospace, Chemical

Select a high risk process & assemble a team

Be sure to include everyone

Risk Priority Number (RPN) / Criticaly Index (CI) = (P x S) x D

Failure modes with high RPNs are usually the most

Design improvements should bring

Focus on preventing defects, enhancing safety, increase

The objective is to look for all ways for process or product

The famous question : What is could happen? Not What

Hybrid prospective analysis model combines concepts :

HFMEA Components and Their Origins

Failure mode &

Severity & Probability

Actions & Outcomes

HACCP : Hazard Analysis Critical Control Point

TIME LINE AND TEAM ACTIVITIES

Identify Topic and notivy the team (Step 1 & 2)

1st team meeting

Diagram the process, identify subprocess, verify the scope

2rd team meeting

Brainstorming failure modes, assign individual team members to

4rd team meeting

Identify failure modes causes, assign individual team members to

5th team meeting

Transfer FM & Causes to the HFMEA Worksheet (Step3). Begin the