FMEA 2016 - Print PDF

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Herkutanto
KETUA KOMITE KESELAMATAN PASIEN

KETUA KONSIL KEDOKTERAN, KKI
Failure Mode and Effect Analysis Guru Besar Fakultas Kedokteran Universitas Indonesia
Herkutanto HERKUTANTO 2
ALASAN UTAMA MELAKUKAN REGULASI

TUJUAN PAPARAN
Strategi
Pengendalian Risiko
melalui FMEA
Mengenal langkah2
Failure Mode and
Effect Analysis
(Schellekens, W : Patient Safety Conference,
European Union Presidency Luxembourg, 4 – 5 April 2005) HERKUTANTO 4
HERKUTANTO, FMEA 1
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KUALITAS PELAYANAN
(Donabedian)
OUTCOME
PROCESS
STRUCTURE
HERKUTANTO 5
HERKUTANTO 6
SUMBER SISTIMATIKA PAPARAN
INTRODUKSI FMEA
DELAPAN LANGKAH FMEA
KESIMPULAN
HERKUTANTO 7 HERKUTANTO 8
HERKUTANTO, FMEA 2
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What is FMEA ?
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
INTRODUKSI FMEA & HFMEA kesalahan akan meminimalkan dampak buruk
What is HFMEA ?
Modified by VA NCPS
FMEA Terminology
Focus on preventing defects, enhancing safety, increase
positive outcome and increase patient satisfaction Process FMEA - Conduct an FMEA on a
process that is already in place
The objective is to look for all ways for process can fail
The famous question : “What is could happen?”

Design FMEA – Conduct an FMEA before
Not “What does happen ?” a process is put into place
Implementing an electronic medical records or
Hybrid prospective analysis model combines concepts : other automated systems
FMEA (Failure Mode and Effects Analysis)
Purchasing new equipment
HACCP (Hazard Analysis Critical Control Points)
RCA (Root Cause Analysis) Redesigning Emergency Room, Operating
Room, Floor, etc.
HERKUTANTO, FMEA 3
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FAILURE MODE AND EFFECTS ANALYSIS Why should my organization

FAILURE (F) : When a system or part of a system
conduct an FMEA ?
performs in a way that is not Can prevent errors & nearmisses protecting
intended or desirable patients from harm.
MODE (M) : The way or manner in which Can increase the effectiveness & efficiency of
something such as a failure can
process
happen. Failure mode is the
manner in which something can Taking a proactive approach to patient safety
fail. also makes good business sense in a health
EFFECTS (E) : The results or consequences of a care environment that is increasingly facing
failure mode demands from consumers, regulators & payers
Analysis (A) : The detailed examination of the to create culture focused on reducing risk &
elements or structure of a process increasing accountability
Where did FMEA come from ?

FMEA has been around for over 30 years
Recently gained widespread appeal
outside of safety area
New to healthcare
Frequently used reliability & system safety
analysis techniques
Long industry track record DELAPAN LANGKAH FMEA
HERKUTANTO, FMEA 4
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LANGKAH-LANGKAH
ANALISIS MODUS KEGAGALAN & DAMPAKNYA Output setiap langkah
(JCI )
LANGKAH OUTPUT
1 Tetapkan Topik FMEA dan Bentuk Tim Topik dan Tim
1. Tetapkan Topik FMEA dan Bentuk Tim
2 Gambarkan Alur Proses Alur Proses tergambar
2. Gambarkan Alur Proses 3 Identifikasi Modus Kegagalan & Modus Kegagalan &
Dampaknya Dampaknya
3. Identifikas Modus Kegagalan & Dampaknya (Hazard Analysis)
4 Tetapkan Prioritas Modus Kegagalan Daftar Prioritas Modus
4. Identifikas Prioritas Modus Kegagalan Kegagalan
5 Identifikasi Akar Penyebab Modus Akar Penyebab
5. Identifikasi Akar Penyebab Modus Kegagalan Kegagalan Modus Kegagalan
6. Disain ulang Proses 6 Disain ulang Proses Proses Baru
7. Analisis dan Test Proses Baru 7 Analisis dan Uji Coba Proses Baru Hasil Uji COba
8 Implementasi dan Monitor Proses Baru Penerapan Proses Baru
8. Implementasi dan Monitor Proses Baru
LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
TUJUAN & HASIL
2 Gambarkan Alur
Proses
3 Identifikasi Modus
1 Kegagalan &
Dampaknya
Terpilihnya Topik FMEA
4 Tetapkan Prioritas
Modus Kegagalan
Terpilihnya TIM Pelaksana untuk topik
5 Identifikasi Akar
Penyebab Modus
Kegagalan tersebut
6 Disain ulang
Proses
TETAPKAN TOPIK & TIM Daftar Tim
7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
Monitor Proses
Baru
HERKUTANTO, FMEA 5
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PEMILIHAN TOPIK FMEA TUJUAN PEMILIHAN TOPIK

Proses spesifik di rumah sakit: Fokus pada proses spesifik yang dianggap
Highrisk prioritas (hospital specific)
Highvolume Melakukan tindakan korektif pada proses
highcost melalui redesign proses
Didasarkan pada data incident report Contoh:
keselamatan pasien Proses pelayanan Transfusi darah
Data rutin keselamatan pasien Proses pemberian obat kepada pasien
Sentinel event
Characteristic of a high risk process LANGKAH 1 : PILIH PROSES YANG BERISIKO TINGGI
Pilih Proses berisiko tinggi yang akan dianalisa.
Variable team Judul Proses :

__________________________________________________________________________
Complex _________________________________________________________
_________________________________________________________
LANGKAH 2 : BENTUK TIM
Non standardized
Ketua :
____________________________________________________________
Tightly coupled
Anggota 1. _______________ 4.
________________________________________
Heavily dependent on human intervention 2. _______________ 5.
________________________________________
3. _______________ 6.
________________________________________
Hierarchical vs team
Notulen? _________________________________________
Apakah semua Unit yang terkait dalam Proses sudah terwakili ? YA / TIDAK
Tight time constraints Tanggal dimulai ____________________ Tanggal selesai ___________________
Loose time constraints HERKUTANTO 23 HERKUTANTO 24
HERKUTANTO, FMEA 6
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TIME LINE AND TEAM ACTIVITIES LANGKAH
1 Tetapkan Topik
Premeeting Identify Topic and notivy the team (Step 1 & 2) FMEA dan Bentuk
Tim
1st team meeting Diagram the process, identify subprocess, verify the scope
2 Gambarkan Alur
2rd team meeting Visit the worksite to observe the process, verify that all process &
subprocess steps are correct (Step 3) Proses
3 rd team meeting Brainstorming failure modes, assign individual team members to 3 Identifikasi Modus
4rd team meeting

consult with process users (Step 3)
Identify failure modes causes, assign individual team members to
2 Kegagalan &
Dampaknya
consult with process users for additional input (Step 3) 4 Tetapkan Prioritas
5th team meeting Transfer FM & Causes to the HFMEA Worksheet (Step3). Begin the Modus Kegagalan
hazard analysis (Step 4) 5 Identifikasi Akar
Identify corrective actios and assign follow up responsibilities (Step 5) Penyebab Modus
6th,7th , 8th…. team Assign team members to follow up individual charged with taking Kegagalan
meeting plus 1 corrective action
6 Disain ulang
team meeting plus 2 Refine corrective actions based on feedback Proses
team meeting plus 3 Test the proposed changes Gambarkan Alur Proses 7 Analisis dan Uji
team meeting plus 4 Meet with Top Management to obtain approval for all actions Coba Proses
Postteam meeting The advisor or his/ her designee follow up until all actions are Baru
completed 8 Implementasi dan
Monitor Proses
Baru
TUJUAN & HASIL
Tergambarnya alur / langkah2 PROSES

dan SUBPROSES pelayanan yang dipilih
dalam suatu bagan yang jelas
LEMBAR ALUR
PROSES dan SUBPROSES PELAYANAN
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LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
Kegagalan &
3 Dampaknya
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang Proses
Identifikasi
7 Analisis dan Uji Coba
Modus Kegagalan & Proses Baru
Dampaknya 8 Implementasi dan

HERKUTANTO 29 HERKUTANTO Monitor Proses30Baru
HAZARD vs RISK vs.

TUJUAN & HASIL COMPLICATIONS
1. Teridentifikasinya MODUS KEGAGALAN 1. A hazard is something that can cause harm, e.g. electricity, chemicals,
working up a ladder, noise, a keyboard, a bully at work, stress, etc. [...
tindakan medik ...??]
pada setiap langkah proses pelayanan 2. Complications are things that happen as a result of a disease or a
treatment that you prefer didn't happen [stroke from hypertension, or
bleeding following surgery]
2. Teridentifikasinya DAMPAK KEGAGALAN A complication may be described as an adverse event caused by pre-
existing factors that were outside the doctor’s control. Patients are not the
pada setiap langkah proses pelayanan same in health, habits, immunity or healing power, and have varying susceptibility
to complications
3. A risk is the chance, high or low, that any hazard will actually cause
somebody harm.
Risk factors are things that make it more likely that you will develop a
disease or condition. They may be things you can't do anything about,
like gender, family history, or race, or things you can control, like smoking
HERKUTANTO 31 and diet. HERKUTANTO 32
HERKUTANTO, FMEA 8
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DIFFERENCES BETWEEN RISKS vs COMPLICATIONS Hazard analysis: What is it?
RISKS COMPLICATIONS Hazard: Potentially dangerous condition,

Allergy Anaphylactic Rx which is triggered by an event,
called the cause of the hazard.
Leucocytosis Sepsis
Bleeding Hypovolemic shock Risk: hazard that is associated with a

Fragile tissues Tissue damage severity and a probability of
occurrence.
Naucea / vomit Hyponatraemia
Hazard, Barrier, Target Analysis
Hazard Barrier Target
High
Dog Fence Child
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HERKUTANTO, FMEA 10
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Hazard, Barrier, Target Analysis

PENERAPAN HBA PADA FMEA
Hazard Target Prinsip: the DEVILS are in the DETAILS

Barrier
Cari modus / cara suatu langkah dalam

suatu subproses dapat gagal
Medical Policies
Procedures Patient
Mishaps
DIAGRAM THE PROCESS

PROCESS STEPS :
Hazard analysis: What is it?

Describe the process graphically, according to your policy & procedure for the activity and number each one
If the process is complex you may want to select one process step or sub process to work on
1 2 3 4 5
Prescribing, Preparing
Selection & Storage
Procurement
Ordering,
Trancribing
&
Dispensin
g
Administration
Hazard analysis: Identify all possible
hazards potentially created by a
Failure Mode Failure Mode Failure Mode Failure Mode Failure Mode product, process or application.
Pemesanan obat Penyimpanan Penulisan obat Peracikan obat Wrong drug
Berlebihan (tdk vaksin tdk dlm R/ tdk jls tdk sesuai dosis
Sesuai kebthn) sesuai suhunya
Wrong dosage
Penulisan Obat R/
Risk assessment: It is the next step
tdk R/
Dlm formularium Wrong frequence after the collection of potential
Wrong route
administration hazards. Risk in this context is the
HERKUTANTO 43
probability and severity of the hazard
HERKUTANTO 44
becoming reality.
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Hazard analysis: What is it? Hazard analysis: What is it?
General risk assessment

protocol : These parameters can
be limits of the
machine or design,
limits on uses, limits
on the scope of the
analysis, or other
limits.
The nature of this

step lends itself to a Two risk factors are used:
team approach such • severity of injury
as brainstorming.
• probability of occurrence
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Risk matrix: Remedy actions are taken to

reduce risks following the
hazard hierarchy:
• Eliminate hazards through the design
Protect
Warn the user
Train the user(s)
If the risk is determined to not be acceptable, it Personal protective equipment

is necessary to reduce that risk by
implementing protective measures.
This assessment
verifies that the
remedy actions have
reduced the risks to an
acceptable level. The documentation can be added to a
technical file for future use.
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Full Hazard Analysis Completed Hazards & Effects Register
Proactive Controls Reactive Controls

HAZARDS & EFFECTS REGISTER
Risk
Recovery Hazard ThreatsBarriers Top Recovery ConsequencesRating Initial Final Remedial
People
Threat Barrier Barrier Measures Event Measures Risk Risk Action
P A E R Required
Recovery Asset
Threat Barrier Barrier C5
Hazard Top Event Measures Damage X X X X X X X X X X D4,5 X
(Incident) E3,4,5
Recovery Environment
Threat Barrier Barrier Measures
X X X X X X X X
Recovery
Measures Reputation
Escalation C5
controls X X X X X X X X X X D4,5
E3,4,5
X X X X X X X X X
LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
4 Kegagalan &
Dampaknya
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang Proses

Tetapkan Prioritas 7 Analisis dan Uji Coba
Modus Kegagalan Proses Baru
8 Implementasi dan
Monitor Proses Baru
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TUJUAN & HASIL
Tersedianya urutan prioritas
DAFTAR PRIORITAS MODUS

KEGAGALAN
ANALISIS HAZARD “LEVEL DAMPAK”

DAMPA MINOR MODERAT MAYOR KATASTROPIK
K 1 2 3 4
ANALISIS HAZARD ”LEVEL PROBABILITAS”
Kegagalan yang tidak Kegagalan dapat Kegagalan Kegagalan menyebabkan
mengganggu Proses mempengaruhi menyebabkan kerugian kerugian besar
pelayanan kepada proses dan berat LEVEL DESKRIPSI CONTOH
Pasien menimbulkan
kerugian ringan 4 Sering (Frequent) Hampir sering muncul dalam waktu yang
Pasien Tidak ada cedera, Cedera ringan Cedera luas / berat Kematian relative singkat (mungkin terjadi
Tidak ada Ada Perpanjangan Perpanjangan hari Kehilangan fungsi tubuh beberapa kali dalam 1 tahun)
perpanjangan hari rawat rawat secara permanent (sensorik,
hari rawat lebih lama (+> 1 bln) motorik, psikologik atau
Berkurangnya fungsi intelektual) mis :
permanen organ tubuh Operasi pada bagian atau 3 Kadang-kadang Kemungkinan akan muncul
(sensorik / motorik / pada pasien yang salah, (Occasional) (dapat terjadi bebearapa kali dalam 1
psikcologik / Tertukarnya bayi sampai 2 tahun)
intelektual)
2 Jarang (Uncommon) Kemungkinan akan muncul

Pengunj Tidak ada cedera Cedera ringan Cedera luas / berat Kematian
ung Tidak ada Ada Penanganan Perlu dirawat Terjadi pada > 6 orang (dapat terjadi dalam >2 sampai 5 tahun)
penanganan ringan Terjadi pada 4 -6 pengunjung
Terjadi pada 1-2 org Terjadi pada 2 -4 orang 1 Hampir Tidak Pernah Jarang sekali terjadi (dapat terjadi dalam
pengunjung pengunjung pengunjung (Remote) > 5 sampai 30 tahun)
Staf: Tidak ada cedera Cedera ringan Cedera luas / berat Kematian
Tidak ada Ada Penanganan / Perlu dirawat Perawatan > 6 staf
penanganan Tindakan Kehilangan waktu /
Terjadi pada 1-2 staf Kehilangan waktu kecelakaan kerja pada
Tidak ada kerugian / kec kerja : 2-4 4-6 staf
HERKUTANTO, FMEA 15
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HAZARD SCORE
TINGKAT BAHAYA
KATASTROPIK MAYOR MODERAT MINOR
4 3 2 1
SERING 16 12 8 4
4
KADANG 12 9 6 3
3
JARANG 8 6 4 2
2
HAMPIR TIDAK 4 3 2 1
PERNAH
1
Laboratory Test Ordering Process
HERKUTANTO, FMEA 16
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LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
TUJUAN & HASIL
2 Gambarkan Alur
Proses
3 Identifikasi Modus Teridentifikasinya AKAR PENYEBAB
5 Kegagalan &
Dampaknya
modus kegagalan yang telah teridentifikasi
Modus Kegagalan
5 Identifikasi Akar Lembar AKAR PENYEBAB
Penyebab Modus
Kegagalan
6 Disain ulang
Identifikasi Akar Penyebab Proses
7 Analisis dan Uji
Modus Kegagalan Coba Proses
Baru
8 Implementasi dan
Monitor Proses
Baru
Possible Characteristics of Root many of the failure modes

Causes
had the same root causes
Omission errors secondary to automatic stop order
Root causes are systemic.
Suboptimal patient involvement in medication histories
Suboptimal medication reconciliation by clinicians
Root causes appear far from the origin of
the failure. Confusing epidural and patient-controlled analgesia
order sets
Lack of electronic medication administration record
The origins of root causes lie in common-
Lack of computerized order entry
cause variation of organization systems
HERKUTANTO, FMEA 17
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PROBING What could happen? - FACTORS

to uncover root causes and their relationships
Human factors
What could happen? (the failure mode)
failure to follow policieson precaution orders or failure
Why could this happen? to conduct appropriate staff education/training
That is, what are the most proximate causes? These
typically involve special-cause variations. Assessment process factors
faulty initial assessment process
Why could these proximate causes happen?
That is, what systems and processes underlie those
proximate causes?
Equipment factors
Common-cause variation here may lead to special- nonfunctional paging system that delays
cause variation in dependent processes.
communication with the individual’s physician
Questions to Uncover Causes
What could happen?

What safeguards are missing in the process?
If the process already contains safeguards (for
example, double checks), why might they not work to
prevent the failure every time?
What would have to go wrong for a failure like

this to happen?
If this failure occurred, why would the problem

not be identified before it affected an individual?
HERKUTANTO, FMEA 18
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Contributory Factors to Suicide DIABETES SCREENING
What could happen?
What could happen?

LANGKAH
Laboratory Test 1 Tetapkan Topik
Ordering Process FMEA dan Bentuk
Tim
2 Gambarkan Alur
Proses
6 Kegagalan &
Dampaknya
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Proses
Disain Ulang Proses 7 Analisis dan Uji
Coba Proses
Baru
8 Implementasi dan
Monitor Proses
Baru
HERKUTANTO, FMEA 19
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Decision Tree
TUJUAN & HASIL Gunakan Decision Tree utk menentukan apakah modus perlu tindakan lanjut di“Proceed”.
Does this hazard involve a

sufficient likelihood of
occurrence and severity to NO
Teridentifikasinya PROSES BARU yang warrant that it be controlled?
(Hazard score of 8 or
higher)
bebas dari modus kegagalan Is this a single point weakness in
NO
YES the process? (Criticality – failure
results in a system failure?)
CRITICALITY
Lembar langkah2 PROSES BARU YES
Does an effective control measure already exist YES
for the identified hazard? STOP
CONTROL THE HAZARD (=BARRIER) Do not proceed
NO to find potential
causes for this
Is this hazard so obvious and readily failure mode
apparent that a control measure is not YES
warranted?
DETECTABILITY NO
(FORESEEABILITY)
Proceed to Potential
HERKUTANTO 77 HERKUTANTO
Causes for this 78
failure mode
PREPARING TO REDESIGN REDESIGN STRATEGIES
Conduct a literature search to gather Prevent the failure from happening

(decrease likelihood of occurrence)
relevant information from the professional Prevent the failure from reaching the
literature. Do not reinvent the wheel individual (increase detectability)
Protect individuals if a failure occurs
Network with colleagues (decrease the severty of the efects)
Recommit to out of the box thinking
HERKUTANTO, FMEA 20
PD PD
!
W
W
O
O
N
N
y
y
bu
bu
to
to
k
k
lic
lic
C
C
w
w
m
m
w w
w
w
o
o
.d o .c .d o .c
PROSES METODE REDESIGN PROCESS

RISIKO TINGGI REDESIGN Process Failure Potential Potential Redesign PIC Target New Outcome
Mode Effect Causes Recommend Completi Process Measure /
ations on Implementat Monitoring
Variable input date ion mechanism
Decreasing variability for test date &
Complex Simplify Actions
Nonstandarized Standardizing
Tightly Coupled Loosen coupling of process
1 2 3 4 5 6 7 8 9
Dependent on human Use technology
intervention Optimise Redundancy
Built in fail safe mechanism
Time constraints
Documentation
Hierarchical culture Establishing a culture of
teamwork
LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
Proses
Redesign 2 Gambarkan Alur
Proses
Bandingkan : 7 Kegagalan &

Dampaknya
Modus Kegagalan
Analisis & Ranking Analisis & Ranking 5 Identifikasi Akar
Penyebab Modus
Kegagalan
Failure Failure 6 Disain ulang
Causes
Mode Effect Causes Mode Effect Analisis dan Uji Coba Proses
7 Analisis dan Uji
Proses Baru Coba Proses
Baru
Proses Lama Proses Baru
8 Implementasi dan
Monitor Proses
Baru
HERKUTANTO, FMEA 21
PD PD
!
W
W
O
O
N
N
y
y
bu
bu
to
to
k
k
lic
lic
C
C
w
w
m
m
w w
w
w
o
o
.d o .c .d o .c
TUJUAN & HASIL SIKLUS PDSA
Terujinya PROSES BARU dilapangan
Le
SIKLUS PDSA
LEMBAR KERJA
UJI COBA
HERKUTANTO, FMEA 22
PD PD
!
W
W
O
O
N
N
y
y
bu
bu
to
to
k
k
lic
lic
C
C
w
w
m
m
w w
w
w
o
o
.d o .c .d o .c
LANGKAH
1 Tetapkan Topik
FMEA dan Bentuk
Tim
LEMBAR KERJA 2 Gambarkan Alur
Proses
UJI COBA 3 Identifikasi Modus
8 Kegagalan &
Dampaknya
Modus Kegagalan
5 Identifikasi Akar
Penyebab Modus
Kegagalan
6 Disain ulang
Implementasi & Monitor Proses
7 Analisis dan Uji
Proses Baru Coba Proses
Baru
8 Implementasi
HERKUTANTO 89 HERKUTANTO
dan Monitor 90
Proses Baru
Strategies for Creating and Managing

TUJUAN & HASIL the Change Process
PENERAPAN PROSES BARU Establish a sense of urgency
Create a guiding coalition

Manajemen Perubahan
Develop a vision and strategy
Lembar MONITORING PROSES BARU Communicate the changed vision
Empower broad-based action
Generate short-term wins
Consolidate gains and produce more change
HERKUTANTO 91 Anchor new approaches HERKUTANTO

in the culture 92
HERKUTANTO, FMEA 23
PD PD
!
W
W
O
O
N
N
y
y
bu
bu
to
to
k
k
lic
lic
C
C
w
w
m
m
w w
w
w
o
o
.d o .c .d o .c
LEMBAR MONITOR PROSES BARU LEMBAR MONITOR PROSES BARU
KESIMPULAN
PROSES BARU YANG LEBIH AMAN
KEBIJAKAN & SOP LEBIH BAIK
RUMAH SAKIT YANG AMAN
HERKUTANTO, FMEA 24

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KETUA KOMITE KESELAMATAN PASIEN

ALASAN UTAMA MELAKUKAN REGULASI

SUMBER SISTIMATIKA PAPARAN

DELAPAN LANGKAH FMEA

Adalah proses proaktif, dimana kesalahan

The famous question : “What is could happen?”

FAILURE MODE AND EFFECTS ANALYSIS Why should my organization

Where did FMEA come from ?

PEMILIHAN TOPIK FMEA TUJUAN PEMILIHAN TOPIK

Pilih Proses berisiko tinggi yang akan dianalisa.

Variable team Judul Proses :

Loose time constraints HERKUTANTO 23 HERKUTANTO 24

4rd team meeting

TUJUAN & HASIL

Tergambarnya alur / langkah2 PROSES

Dampaknya 8 Implementasi dan

HAZARD vs RISK vs.

DIFFERENCES BETWEEN RISKS vs COMPLICATIONS Hazard analysis: What is it?

RISKS COMPLICATIONS Hazard: Potentially dangerous condition,

Bleeding Hypovolemic shock Risk: hazard that is associated with a

Hazard, Barrier, Target Analysis

Hazard Barrier Target

Hazard, Barrier, Target Analysis

Hazard Target Prinsip: the DEVILS are in the DETAILS

Cari modus / cara suatu langkah dalam

DIAGRAM THE PROCESS

Hazard analysis: What is it?

Hazard analysis: What is it? Hazard analysis: What is it?

General risk assessment

Hazard analysis: What is it? Hazard analysis: What is it?

The nature of this

Hazard analysis: What is it? Hazard analysis: What is it?

Risk matrix: Remedy actions are taken to

If the risk is determined to not be acceptable, it Personal protective equipment

Hazard analysis: What is it? Hazard analysis: What is it?

Full Hazard Analysis Completed Hazards & Effects Register

Proactive Controls Reactive Controls

6 Disain ulang Proses

TUJUAN & HASIL

Tersedianya urutan prioritas

DAFTAR PRIORITAS MODUS

ANALISIS HAZARD “LEVEL DAMPAK”

2 Jarang (Uncommon) Kemungkinan akan muncul

Laboratory Test Ordering Process

Possible Characteristics of Root many of the failure modes

PROBING What could happen? - FACTORS

Questions to Uncover Causes

What could happen?

What would have to go wrong for a failure like

If this failure occurred, why would the problem

Contributory Factors to Suicide DIABETES SCREENING

What could happen?

What could happen?

Does this hazard involve a

PREPARING TO REDESIGN REDESIGN STRATEGIES

Conduct a literature search to gather Prevent the failure from happening

PROSES METODE REDESIGN PROCESS

Bandingkan : 7 Kegagalan &

TUJUAN & HASIL SIKLUS PDSA

Terujinya PROSES BARU dilapangan

Strategies for Creating and Managing

PENERAPAN PROSES BARU Establish a sense of urgency