LANGKAH 7

1.
2.
3.
4.
5.

LATAR BELAKANG PERLUNYA REDESAIN PROSES DI

PELAYANAN KESEHATAN
STANDARD JCAHO : IDENTIFIKASI RISIKO SECARA
PROAKTIF
STRATEGI REDUKSI RISIKO
IDENTIFIKASI PROSES YG RISIKO TINGGI
REDISAIN PROSES :
- FMEA
- AMKD / HFMEA

Arjaty/ IMRK

Historical Perspective
Hingga

saat ini, pencegahan kesalahan medis belum

Until recently, error prevention has not been a
menjadi fokus utama bidang kedokteran

primary focus of medicine

Kelainan

Sistem atau proses diidentifikasi dari

System/process defects are identified by
kejadian yang tidak diharapkan atau disembunyikan
adverse
events
oleh
tenaga
medis or dealt with silently by health

care personnel

Sebagian

besar sistem pelayanan kesehatan tidak

didesain
Most health
delivery
are not
untukcare
mencegah
atausystems
mengkompensasi
designed
to prevent and / or compensate for
suatu
kesalahan

errors

Arjaty/ IMRK

Rationale for FMEA in healthcare

Pencegahan
Historically
.......insiden belum menjadi fokus
Accident
utama pelayanan
rumah
sakit
prevention
has not
been a primary
of hospital
focus
Adanya
persepsimedicine
yang salah tentang
Misguided
on faultles
performance
kegagalanreliance
dalam pelayanan
oleh
profesi
by
healthcare professionals
kesehatan

systems
were
notdidesain
designed
to
Hospital
Sistem rumah
sakit
tidak
untuk
prevent
or absorb
error,mereka
they just
reactively
mencegah
kesalahan,
hanya
reaktif
changed and were not typically proactive
dan tidak proaktif
Arjaty/ IMRK

NCPS

JCAHO Standards
PI.3.20*

An
Anongoing,
ongoing,proactive
proactiveprogram
programfor
foridentifying
identifyingand
and
reducing
reducingunanticipated
unanticipatedadverse
adverseevents
eventsand
andsafety
safety
risks
riskstotopatients
patientsisisdefined
definedand
andimplemented.
implemented.
At
leastsedikit,
one high-risk
process
is chosen
annually,
thetahunnya
choice ,
Paling
pilih satu
masalah
berisiko
tinggi tiap
berdasarkan
evaluasi
periodikperiodically
should be basedpilih
in part
on information
published
by the Joint Commission about the most frequent sentinel
events and risks.

Arjaty/ IMRK
*2005 Comprehensive Accreditation Manual for Hospitals:
The Official Handbook JCAHO 2005

JCAHO Standard LD 5.2

(efective July 2001)

Leaders
Pimpinanensure
perlu memastikan
that an ongoing,
bahwa
proactive
seluruhprogram
upaya

berjalan
dalam penerapan
program
proaktif
for identifying
risks to patient
safetysecara
andreducing
medical
mengidentifikasi
risikoerrors
yangistujuannya
bagi
/ health care
defined and
keselamatan pasien implemented
dan mereduksi kesalahan medis

The organization
seeksmereduksi
to reduce the
riskkejadian
of sentinel
events and
Organisasi
akan berusaha
risiko
berbahaya
ataumedical

/ healthmedis
care system
relatedusaha
occurrences
conducting itsinformasi
own
kesalahan
denganerror
melakukan
proaktifby
menggunakan
proactive
and bykesamaan
using available
information
yang
tersediarisk
dariassessment
kejadian lainactivities
yang memiliki
pelayanan
dan
about sentinel events known to occur in healthcare organizations that
sistem
provide similar care & services.
Upaya untuk redesain ulang proses fungsi dan pelayanan sehingga dapat
Thiskejadian
effort is undertaken
so that
processes, functions & services can be
dicegah
yang merugikan
organisasi
DESIGNED or REDEDIGNED to prevent such occurrences in the
organization.
Arjaty/ IMRK

JCAHO Standard LD 5.2

(efective July 2001)
Identify and prioritize high risk processes
Identifikasi dan proritaskan proses yang
Annually
berisiko select
tinggi at least one high risk process
Identify
potential
failure
modes
Identifikasi
potensi
modus
kegagalan
For
eachmodus
failurekegagalan,
mode, identify
possible
Setiap
identifikasi
dampak

effects
yang mungkin terjadi
For
the setiap
most critical
effects,
a root
Untuk
dampak
yang conduct
kritis, lakukan
cause
analysis
analisis
akar masalah.
Arjaty/ IMRK

JCAHO Standard LD 5.2

(efective July 2001)
Redesign

process to minimize the risk of that

Redisainthe
proses untuk meminimalisasi risiko

failure mode or to protect patients from its effects

modus kegagalan atau mencegah dampaknya
Test and implement the redesigned process
pada pasien
Identify and implement measures of effectiveness
Uji coba dan implementasi redisain proses
Implement a strategy for maintaining the
effectiveness
Identifikasi of
dan
efektivitas
implementasi
thenilai
redesigned
process
over
proses redisain.
timeatau
Implementasikan
strategi untuk efektivitas

maintanance
Arjaty/ IMRK

RISK REDUCTION STRATEGIES DIFFICULTY &

LONG TERM EFFECTIVENESS
Types of actions

Degree of
difficulty
Easy

2.

Punitive
Retraining / counseling

3.

Process redesign

4.

Paper vs practice
Technical system enhance
Culture change

1.

5.
6.

Difficult
Arjaty/ IMRK

Long term
effectiveness
Low

High
9

Definition of a Process
A goal-directed

interrelated series of
events, activities, actions, mechanisms, or
steps that transform inputs into outputs
(CAMH Glossary)

Arjaty/ IMRK

10

STRATEGI REDUKSI RISIKO

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

Arjaty/ IMRK

11

STRATEGI REDUKSI RISIKO

RISK
POINTS /
COMMON CAUSES

RENCANA
REDUKSI RISIKO

Design Proses u/ Design Proses u/

Design Proses u/
Meminimalkan
Mengurangi
Meminimalkan
risiko
Dampak
risiko
Kegagalan terjadi Kegagalan terjadi
kegagalan Arjaty/ IMRK
12
Pada pasien
pada pasien

Choosing the Process

High

Risk processes

Identified

in the literature
Identified by JCAHO
Identified through safety alerts
New

or redefined process
Staff recommendations

Arjaty/ IMRK

13

IDENTIFYING RISK PRONE SYSTEM

Variable

input
Complex systems
Non standardized systems
Tightly coupled systems
Systems with tight time constraints
Systems with hierarchical

Arjaty/ IMRK

14

Variable input
Pasien
Penyakit berat
Penyakit penyerta
Pernah mendapatkan pengobatan
Usia
Pemberi Pelayanan
Tingkat keterampilan
Cara pendekatan
Proses Pelayanan harus dapat mengakomodasi
variabilitas yang tdk dapat dihindarkan dan tidak dapat
dikontrol ini.
Arjaty/ IMRK

15

Complexitas
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%
Arjaty/ IMRK

16

Lack of Standardization
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.
Arjaty/ IMRK

17

Heavily dependent on human Intervention

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
Arjaty/ IMRK

18

Tightly Coupled
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
Arjaty/ IMRK

19

Hierarchical culture

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 berkomunikasi antar staf dalam proses pelayanan

kesehatan sangat menentukan hasilnya.
Arjaty/ IMRK

20

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
Arjaty/ IMRK

21

REDISAIN PROSES
FMEA

Variable input
Complex
Nonstandarized
Tightly Coupled
Dependent on human
intervention
Time constraints
Hierarchical culture

Arjaty/ IMRK

Decreasing variability
Simplify
Standardizing
Loosen coupling of process
Use technology
Optimise Redundancy
Built in fail safe mechanism
Documentation
Establishing a culture of
teamwork
22

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 kesalahan akan meminimalkan dampak
buruk

Arjaty/ IMRK

23

FMEA
Whats the point?
Dengan
mengeliminasi
atau
mereduksi
Eliminating
or reducing
the risk
of the
failure modes
result
in a
risiko kegagalancan
akan
menghasilkan
suatu
SAFER AND
SISTEM
YANGMORE
AMANEFFICIENT
DAN LEBIHSYSTEM
EFISIEN
from which BAGI
both you
patients
benefit.
RS and
DANyour
PASIEN
.

Arjaty/ IMRK

24

What is Failure Mode and Effect Analysis

(FMEA) ?
A tool to :
-Analyze a process to see where it is likely to fail
-See how changes you are considering might affect
the safety of the process

Arjaty/ IMRK

25

Failure Mode and Effects Analysis

1. Define failure mode.
what could go wrong?

2. Identify cause of failure.

3. Identify effects of failure

4. Corrective action.

why would the failure

happen?
what would be the
consequences of each
failure?

Arjaty/ IMRK

26

FMEA Terminology
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
Implementing

an electronic medical records or

other automated systems
Purchasing new equipment
Redesigning Emergency Room, Operating Room,
Floor, etc.
Arjaty/ IMRK

27

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
Arjaty/ IMRK

28

Why should my organization

conduct an FMEA ?
Can prevent errors & nearmisses 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

Arjaty/ IMRK

29

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 : Aviation, Nuclear

power, Aerospace, Chemical process

industries, Automoive
Arjaty/ IMRK

30

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
Arjaty/ IMRK

31

Step Three
Have the team list failure modes and effect
List anything that could go wrong including minor
and rare problems
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

Arjaty/ IMRK

32

Arjaty/ IMRK

33

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
Arjaty/ IMRK

34

Step Six
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
Arjaty/ IMRK

35

Step Seven
Analyze and test the new process
Use RPNs to plan improvement efforts

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.

Arjaty/ IMRK

36

Step Eight
Implement & monitor the redesigned process
Design

improvements should bring reduction

in the CI / RPN.
Ex: 30 50% reduction ?

Arjaty/ IMRK

37

Arjaty/ IMRK

38

LANGKAH2 FMEA, HFMEA, 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 De)

Graphically describe
the Process

Brainstorm potential failure modes

(P X S) x K X De, Bands

Prioritize failure modes

Conduct a Hazard
Analysis

Prioritize failure modes

Identify root causes of failure modes

(P X S X De)

Actions & Outcome

Measures

Identify root causes of failure modes

(P X S) x K X De, Bands

REDESIGN THE PROCESS

Analyze & test the new process

Implement & monitor the redesigned

process

CALCULATE TOTAL RPN

REDESIGN THE PROCESS
Analyze & test the new process
Arjaty/ IMRK

Implement & monitor the redesigned

39
process

RATING SYSTEM
(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

Arjaty/ IMRK

40

What is HFMEA ?
Modified by VA NCPS

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)
Arjaty/ IMRK

41

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

Arjaty/ IMRK

HACCP : Hazard Analysis Critical Control Point

42

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
Arjaty/ IMRK

43

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
Define

the Scope of HFMEA along with a clear

definition of the process to be studied

Step 2
Multidisiplinary

team with Subject matter

expert(s) plus advisor
Arjaty/ IMRK

45

Step 3
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
Arjaty/ IMRK

46

Step 4
List

Failure modes
Determine Severity & Probability
Use the Decision tree
List all Failure mode causes

Arjaty/ IMRK

47

Step 5
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
Arjaty/ IMRK

48

FORM & TOOLS

Form
Worksheets
Hazard

Scoring matrix
Decision tree

Arjaty/ IMRK

49

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 ___________________

Arjaty/ IMRK

50

Contoh kasus 1

Arjaty/ IMRK

51

Arjaty/ IMRK

52

Arjaty/ IMRK

53

ANALISIS
DAMPAK

Pasien

MINOR
1

MODERAT
2

Kegagalan menyebabkan
kerugian berat

Kegagalan menyebabkan kerugian

besar

Tidak ada cedera,

Cedera ringan

Cedera

luas / berat
Perpanjangan hari rawat
lebih lama (+> 1 bln)
Berkurangnya fungsi
permanen organ tubuh
(sensorik / motorik /
psikcologik / intelektual)

Cedera ringan
Ada Penanganan
ringan
Terjadi pada 2 -4
pengunjung

Cedera luas / berat

Perlu dirawat
Terjadi pada 4 -6 orang
pengunjung

Kematian
Terjadi pada

Cedera ringan
Ada Penanganan /

Cedera luas / berat

Perlu dirawat

Kematian
Perawatan

Tidak ada perpanjangan

Tidak ada cedera

Tidak ada penanganan
Terjadi pada 1-2

org

Tidak ada cedera

Tidak ada penanganan
Terjadi pada 1-2 staf
Tidak ada kerugian

Fasilitas
Kes

KATASTROPIK
4

Kegagalan dapat
mempengaruhi proses
dan menimbulkan
kerugian ringan

pengunjung
Staf:

MAYOR
3

Kegagalan yang tidak

mengganggu Proses
pelayanan kepada Pasien

hari rawat

Pengunju
ng

HAZARD LEVEL DAMPAK

Ada

Perpanjangan
hari rawat

waktu / keckerja

Tindakan
Kehilangan waktu /
kec kerja : 2-4 staf

Kerugian < 1 000,,000

atau tanpa menimbulkan
dampak terhadap pasien

Kerugian
1,000,000 10,000,000

Kematian
Kehilangan fungsi tubuh
secara permanent (sensorik,
motorik, psikologik atau
intelektual) mis :
Operasi pada bagian atau
pada pasien yang salah,
Tertukarnya bayi
> 6 orang

pengunjung

> 6 staf

Kehilangan

waktu /
kecelakaan kerja pada
4-6 staf

Kerugian
10,000,000 - 50,000,000
Arjaty/ IMRK

Kerugian > 50,000,000

54

ANALISIS HAZARD LEVEL PROBABILITAS

LEVEL

DESKRIPSI

CONTOH

Sering (Frequent)

Hampir sering muncul dalam waktu yang

relative singkat (mungkin terjadi beberapa
kali dalam 1 tahun)

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 > 5
(Remote)
sampai 30 tahun)
Arjaty/ IMRK

55

HAZARD SCORE
TINGKAT BAHAYA
KATASTROPIK
4

MAYOR
3

MODERAT
2

MINOR
1

SERING
4

16

12

KADANG
3

12

JARANG
2

HAMPIR TIDAK
PERNAH
1

Arjaty/ IMRK

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

NO

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
Arjaty/ IMRK

YES

STOP

YES

NO

Proceed to
Potential
Causes for
this failure

Do not proceed to
find potential
causes for this
failure mode

57

Arjaty/ IMRK

58

Arjaty/ IMRK

59

Contoh kasus 2
PROSES KEGIATAN PAGI HARI MENUJU TEMPAT KERJA

Arjaty/ IMRK

60

Arjaty/ IMRK

61

Arjaty/ IMRK

62

Arjaty/ IMRK

63

Arjaty/ IMRK

64

Arjaty/ IMRK

65

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66

Arjaty/ IMRK

67

LEMBAR AMKD ( FORM HFMEA )

AMKD Langkah 4 - Analisis Hazard
SKORING

Analisis Pohon Keputusan

Occasi
onal

N
N

Arjaty/ IMRK
HFMEA : Healthcare Failure Mode Effect and Analysis

Tipe
Tindakan
(Kontrol,
terima,
Eliminasi)

Manajemen Tim

major

Yang Bertanggung Jawab

Ukuran Outcome

occasi
onal

Proses ?

major

Tindakan /
Alasan untuk
mengakhiri

Apakah mudah didteksi ?

Nilai Hazard

Missed snooze
button

Probabilitas

Kegawatan

Turn off alarm

Apakah ada kontrol/pengendalian?

POTENSI
PENYEBAB

Poin Tunggal Kelemahan ?

MODUS
Kegagalan :
Evaluasi awal
modus
kegagalan
sebelum

AMKD Langkah 5 - Identifikasi Tindakan & Outcome

Y
Y

Eliminate

Purchased
new clock

Purc
hase
d by
certai
n
date..
...

Mr..

Yes

68

AMKD / HFMEA
Proses lama
yg high risk
Alur
Proses

Potential Cause
Failure
Mode

Efek /
Dampak
HS

Decision
Tree
K
K
D

Desain
Proses baru

Hazard
Score

Arjaty/ IMRK

Kritis
Kontrol
Deteksi

Tindakan
K
E
T
Kontrol
Eliminasi
Terima

69

AMKDP / HFMECA

Prioritas
risiko

Total RPN
PROSES
LAMA

Failure

Redisign
Proses

Mode,

Analisis &
Uji Proses Baru
Total RPN
PROSES
BARU

Dampak,
Penyebab
Total RPN
30-50%?

Arjaty/ IMRK

Implementasi
PROSES BARU

Failure
Mode,
Dampak,
Penyebab

70

CONTOH IMPLEMENTASI KESELAMATAN PASIEN

The JCI 2007
International Patient Safety Goals
1.

Identifikasi pasien dengan benar

2.

Tingkatkan komunikasi efektif

3.

Tingkatkan keamanan untuk pemberian obat

yang berisiko tinggi

4.

Eliminasi salah sisi, salah pasien, salah

prosedur operasi

5.

Reduksi risiko infeksi nosokomial

6.

Reduksi risiko pasien cedera dari jatuh

Arjaty/ IMRK

71

TINGKATKAN KOMUNIKASI
EFEKTIF
Handover
Read back
Repeat back
Check back
Teach back

Arjaty/ IMRK

72

Tingkatkan keamanan untuk pemberian

obat
LASA / NORUM
CHECK BACK
5 BENAR
JANGAN GUNAKAN
SINGKATAN

Arjaty/ IMRK

73

LOOK ALIKE SOUND ALIKE

Arjaty/ IMRK

74

JANGAN GUNAKAN SINGKATAN

Arjaty/ IMRK

75

Arjaty/ IMRK

76

BELAJAR DARI PENGALAMAN

Arjaty/ IMRK

77

KESIMPULAN
Building a safe healthcare
system

R
A
T
L
E
N
E
T
P
A
U
A
O
L
R
M
R
I
E
W
T
S
I
O
I
N
R
S
G
K
U

L
E
A
R
N
I
N
G

S
E
V
E
R
I
T
Y

F K
D
R
E
T E O
T
M
R K
E
U
A U
K
N
I
S
E
I
N
I
K
N
I
A
S
N
S
I
G
I

K
O
N
T

R
O
L

L E A D E R S H I P
Arjaty/ IMRK

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Arjaty/ IMRK

79