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8/16/2019 Langkah Ke 7-Cegah Cedera Melalui Implementasi Keselamatan Pasien
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8/16/2019 Langkah Ke 7-Cegah Cedera Melalui Implementasi Keselamatan Pasien
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Arjaty/ IMRK Arjaty/ IMRK 22
1.1. LATAR BELAKANG PERLUNYA REDESAIN PROSES DILATAR BELAKANG PERLUNYA REDESAIN PROSES DIPELAYANAN KESEHATANPELAYANAN KESEHATAN
2.2. STANDARD JCAHO : IDENTIIKASI RISIKO SECARASTANDARD JCAHO : IDENTIIKASI RISIKO SECARA
PROAKTIPROAKTI!.!. STRATEGI REDUKSI RISIKOSTRATEGI REDUKSI RISIKO
".". IDENTIIKASI PROSES YG RISIKO TINGGIIDENTIIKASI PROSES YG RISIKO TINGGI
#.#. REDISAIN PROSES :REDISAIN PROSES :
$ MEA$ MEA $ AMKD$ AMKD%% / HMEA/ HMEA
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Arjaty/ IMRK Arjaty/ IMRK !!
H&'t(r&)a* P+r',+)t&-+H&'t(r&)a* P+r',+)t&-+
Ut&* r+)+t*y +rr(r ,r+-+t&( 0a' (t ++ aUt&* r+)+t*y +rr(r ,r+-+t&( 0a' (t ++ a,r&ary 3()4' (3 +5&)&+,r&ary 3()4' (3 +5&)&+
Sy't+/,r()+'' 5+3+)t' ar+ &5+t&3&+5 ySy't+/,r()+'' 5+3+)t' ar+ &5+t&3&+5 ya5-+r'+ +-+t' (r 5+a*t 6&t0 '&*+t*y y 0+a*t0a5-+r'+ +-+t' (r 5+a*t 6&t0 '&*+t*y y 0+a*t0)ar+ ,+r'(+*)ar+ ,+r'(+*
M('t 0+a*t0 )ar+ 5+*&-+ry 'y't+' ar+ (tM('t 0+a*t0 )ar+ 5+*&-+ry 'y't+' ar+ (t5+'&7+5 t( ,r+-+t a5 / (r )(,+'at+ 3(r5+'&7+5 t( ,r+-+t a5 / (r )(,+'at+ 3(r+rr(r'+rr(r'
H&77a 'aat && ,+)+7a0a 8+'a*a0a +5&' +*4H&77a 'aat && ,+)+7a0a 8+'a*a0a +5&' +*4+ja5& 3(84' 4taa &5a7 8+5(8t+ra+ja5& 3(84' 4taa &5a7 8+5(8t+ra
K+*a&a S&'t+ ata4 ,r('+' 5&&5+t&3&8a'& 5ar&K+*a&a S&'t+ ata4 ,r('+' 5&&5+t&3&8a'& 5ar&
8+ja5&a ya7 t&5a8 5&0ara,8a ata4 5&'+4y&8a8+ja5&a ya7 t&5a8 5&0ara,8a ata4 5&'+4y&8a(*+0 t+a7a +5&'(*+0 t+a7a +5&'
S+a7&a +'ar '&'t+ ,+*ayaa 8+'+0ata t&5a8S+a7&a +'ar '&'t+ ,+*ayaa 8+'+0ata t&5a8
5&5+'a& 4t48 +)+7a0 ata4 +78(,+'a'&5&5+'a& 4t48 +)+7a0 ata4 +78(,+'a'&'4at4 8+'a*a0a'4at4 8+'a*a0a
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Arjaty/ IMRK Arjaty/ IMRK ""
Rat&(a*+ 3(rRat&(a*+ 3(r FMEAFMEA & 0+a*t0)ar+& 0+a*t0)ar+
H&'t(r&)a**y .......H&'t(r&)a**y ....... A))&5+t ,r+-+t&( 0a' (t ++ a ,r&ary A))&5+t ,r+-+t&( 0a' (t ++ a ,r&ary
3()4' (3 0(',&ta* +5&)&+3()4' (3 0(',&ta* +5&)&+
M&'74&5+5 r+*&a)+ ( 93a4*t*+' ,+r3(ra)+M&'74&5+5 r+*&a)+ ( 93a4*t*+' ,+r3(ra)+y 0+a*t0)ar+ ,r(3+''&(a*'y 0+a*t0)ar+ ,r(3+''&(a*'
H(',&ta* 'y't+' 6+r+ (t 5+'&7+5 t(H(',&ta* 'y't+' 6+r+ (t 5+'&7+5 t(,r+-+t (r a'(r +rr(r t0+y j4't r+a)t&-+*y,r+-+t (r a'(r +rr(r t0+y j4't r+a)t&-+*y
)0a7+5 a5 6+r+ (t ty,&)a**y ,r(a)t&-+)0a7+5 a5 6+r+ (t ty,&)a**y ,r(a)t&-+
NCPS
P+)+7a0a &'&5+ +*4 +ja5& 3(84'P+)+7a0a &'&5+ +*4 +ja5& 3(84'
4taa ,+*ayaa r4a0 'a8&t4taa ,+*ayaa r4a0 'a8&t
A5aya ,+r'+,'& ya7 'a*a0 t+ta7 A5aya ,+r'+,'& ya7 'a*a0 t+ta7
8+7a7a*a 5a*a ,+*ayaa (*+0 ,r(3+'&8+7a7a*a 5a*a ,+*ayaa (*+0 ,r(3+'&8+'+0ata8+'+0ata
S&'t+ r4a0 'a8&t t&5a8 5&5+'a& 4t48S&'t+ r4a0 'a8&t t&5a8 5&5+'a& 4t48
+)+7a0 8+'a*a0a +r+8a 0aya r+a8t&3+)+7a0 8+'a*a0a +r+8a 0aya r+a8t&35a t&5a8 ,r(a8t&3 5a t&5a8 ,r(a8t&3
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Arjaty/ IMRK Arjaty/ IMRK ##
JCAHO Sta5ar5'JCAHO Sta5ar5'
PI.!.2;
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Arjaty/ IMRK Arjaty/ IMRK >>
JCAHO Sta5ar5 LD #.2JCAHO Sta5ar5 LD #.2?+3+)t&-+ J4*y 2;;1@?+3+)t&-+ J4*y 2;;1@
L+a5+r' +'4r+ t0at a (7(&7 ,r(a)t&-+ ,r(7raL+a5+r' +'4r+ t0at a (7(&7 ,r(a)t&-+ ,r(7ra3(r &5+t&3y&7 r&'8' t( ,at&+t 'a3+ty a5r+54)&73(r &5+t&3y&7 r&'8' t( ,at&+t 'a3+ty a5r+54)&7+5&)a* / 0+a*t0 )ar+ +rr(r' &' 5+3&+5 a5+5&)a* / 0+a*t0 )ar+ +rr(r' &' 5+3&+5 a5
&,*++t+5&,*++t+5
T0+ (r7a&at&( '++8' t( r+54)+ t0+ r&'8 (3 '+t&+* +-+t' a5 +5&)a*/ 0+a*t0 )ar+ 'y't+ +rr(r r+*at+5 ())4rr+)+' y )(54)t&7 &t' (6
,r(a)t&-+ r&'8 a''+''+t a)t&-&t&+' a5 y 4'&7 a-a&*a*+ &3(rat&(
a(4t '+t&+* +-+t' 8(6 t( ())4r & 0+a*t0)ar+ (r7a&at&(' t0at
,r(-&5+ '&&*ar )ar+ '+r-&)+'.
T0&' +33(rt &' 45+rta8+ '( t0at ,r()+''+' 34)t&(' '+r-&)+' )a +
DESIGNED or EDEDIGNED to prevent suc! occurrences in t!e
organi"ation.
P&,&a ,+r*4 +a't&8a a06a '+*4r40 4,ayaP&,&a ,+r*4 +a't&8a a06a '+*4r40 4,aya+rja*a 5a*a ,++ra,a ,r(7ra '+)ara ,r(a8t&3+rja*a 5a*a ,++ra,a ,r(7ra '+)ara ,r(a8t&3 +7&5+t&3&8a'& r&'&8( ya7 t4j4aya a7&+7&5+t&3&8a'& r&'&8( ya7 t4j4aya a7&
8+'+*aata ,a'&+ 5a +r+548'& 8+'a*a0a +5&'8+'+*aata ,a'&+ 5a +r+548'& 8+'a*a0a +5&'
Or7a&'a'& a8a +r4'a0a +r+548'& r&'&8( 8+ja5&a +ra0aya ata4
8+'a*a0a +5&' 5+7a +*a848a 4'a0a ,r(a8t&3 +774a8a &3(ra'&
ya7 t+r'+5&a 5ar& 8+ja5&a *a& ya7 +&*&8& 8+'aaa ,+*ayaa 5a
'&'t+
U,aya 4t48 r+5+'a& 4*a7 ,r('+' 347'& 5a ,+*ayaa '+0&77a 5a,at5&)+7a0 8+ja5&a ya7 +r47&8a (r7a&'a'&
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Arjaty/ IMRK Arjaty/ IMRK
I5+t&3y a5 ,r&(r&t&+ 0&70 r&'8 ,r()+''+'I5+t&3y a5 ,r&(r&t&+ 0&70 r&'8 ,r()+''+'
A4a**y '+*+)t at *+a't (+ 0&70 r&'8 ,r()+'' A4a**y '+*+)t at *+a't (+ 0&70 r&'8 ,r()+''
I5+t&3y ,(t+t&a* 93a&*4r+ (5+'I5+t&3y ,(t+t&a* 93a&*4r+ (5+'
(r +a)0 93a&*4r+ (5+ &5+t&3y ,(''&*+(r +a)0 93a&*4r+ (5+ &5+t&3y ,(''&*+
+33+)t'+33+)t'
(r t0+ ('t )r&t&)a* +33+)t' )(54)t a r((t(r t0+ ('t )r&t&)a* +33+)t' )(54)t a r((t
)a4'+ aa*y'&')a4'+ aa*y'&'
JCAHO Sta5ar5 LD #.2JCAHO Sta5ar5 LD #.2?+3+)t&-+ J4*y 2;;1@?+3+)t&-+ J4*y 2;;1@
I5+t&3&8a'& 5a ,r(r&ta'8a ,r('+' ya7I5+t&3&8a'& 5a ,r(r&ta'8a ,r('+' ya7
+r&'&8( t&77&+r&'&8( t&77&
I5+t&3&8a'& ,(t+'& (54' 8+7a7a*aFI5+t&3&8a'& ,(t+'& (54' 8+7a7a*aF
S+t&a, (54' 8+7a7a*a &5+t&3&8a'& 5a,a8FS+t&a, (54' 8+7a7a*a &5+t&3&8a'& 5a,a8F
ya7 478& t+rja5&ya7 478& t+rja5&
Ut48 '+t&a, 5a,a8 ya7 8r&t&' *a848aUt48 '+t&a, 5a,a8 ya7 8r&t&' *a848a
aa*&'&' a8ar a'a*a0F.aa*&'&' a8ar a'a*a0F.
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Arjaty/ IMRK Arjaty/ IMRK
R+5+'&7 t0+ ,r()+'' t( &&&+ t0+ r&'8 (3 t0atR+5+'&7 t0+ ,r()+'' t( &&&+ t0+ r&'8 (3 t0at
3a&*4r+ (5+ (r t( ,r(t+)t ,at&+t' 3r( &t' +33+)t'3a&*4r+ (5+ (r t( ,r(t+)t ,at&+t' 3r( &t' +33+)t'
T+'t a5 &,*++t t0+ r+5+'&7+5 ,r()+''T+'t a5 &,*++t t0+ r+5+'&7+5 ,r()+''
I5+t&3y a5 &,*++t +a'4r+' (3 +33+)t&-++''I5+t&3y a5 &,*++t +a'4r+' (3 +33+)t&-++'' I,*++t a 'trat+7y 3(r a&ta&&7 t0+I,*++t a 'trat+7y 3(r a&ta&&7 t0+
+33+)t&-++'' (3 t0+ r+5+'&7+5 ,r()+'' (-+r+33+)t&-++'' (3 t0+ r+5+'&7+5 ,r()+'' (-+r
t&+ata4 ,r('+' r+5&'a&.t&+ata4 ,r('+' r+5&'a&.
JCAHO Sta5ar5 LD #.2JCAHO Sta5ar5 LD #.2?+3+)t&-+ J4*y 2;;1@?+3+)t&-+ J4*y 2;;1@
R+5&'a& ,r('+' 4t48 +&&a*&'a'& r&'&8(R+5&'a& ,r('+' 4t48 +&&a*&'a'& r&'&8(
(54' 8+7a7a*a ata4 +)+7a0 5a,a8ya(54' 8+7a7a*a ata4 +)+7a0 5a,a8ya
,a5a ,a'&+,a5a ,a'&+
Uj& )(a 5a &,*++ta'& r+5&'a& ,r('+'Uj& )(a 5a &,*++ta'& r+5&'a& ,r('+'
I5+t&3&8a'& 5a &*a& +3+8t&-&ta' &,*++ta'&I5+t&3&8a'& 5a &*a& +3+8t&-&ta' &,*++ta'&
I,*++ta'&8a 'trat+7& 4t48 +3+8t&-&ta'I,*++ta'&8a 'trat+7& 4t48 +3+8t&-&ta'
a&taa)+a&taa)+
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Arjaty/ IMRK Arjaty/ IMRK
IS# ED$%&I'N S&A&EGIES DIFFI%$(&) *IS# ED$%&I'N S&A&EGIES DIFFI%$(&) *
('NG &EM EFFE%&I+ENESS('NG &EM EFFE%&I+ENESS
Ty,+' (3 a)t&(' D+7r++ (3 L(7 t+rTy,+' (3 a)t&(' D+7r++ (3 L(7 t+r
5&33&)4*ty +33+)t&-++''5&33&)4*ty +33+)t&-++''
Ea'y L(6Ea'y L(6
1.1. P4&t&-+P4&t&-+
2.2. R+tra&&7 / )(4'+*&7R+tra&&7 / )(4'+*&7
.. -rocess redesign-rocess redesign".". 99Pa,+r -' ,ra)t&)+Pa,+r -' ,ra)t&)+
#.#. T+)0&)a* 'y't+ +0a)+T+)0&)a* 'y't+ +0a)+>.>. C4*t4r+ )0a7+C4*t4r+ )0a7+
D&33&)4*t H&70D&33&)4*t H&70
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Arjaty/ IMRK Arjaty/ IMRK 1;1;
Definition of a -rocessDefinition of a -rocess
A 7(a*$5&r+)t+5 &t+rr+*at+5 '+r&+' (3 A 7(a*$5&r+)t+5 &t+rr+*at+5 '+r&+' (3
+-+t' a)t&-&t&+' a)t&(' +)0a&'' (r+-+t' a)t&-&t&+' a)t&(' +)0a&'' (r
't+,' t0at tra'3(r &,4t' &t( (4t,4t''t+,' t0at tra'3(r &,4t' &t( (4t,4t'?CAMH G*(''ary@?CAMH G*(''ary@
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Arjaty/ IMRK Arjaty/ IMRK 1111
S&A&EGI ED$#SI ISI#'S&A&EGI ED$#SI ISI#'
I5+t&3&8a'& r&'&8( 57 +rtaya ! ,+rtayaa 5a'ar :I5+t&3&8a'& r&'&8( 57 +rtaya ! ,+rtayaa 5a'ar : 1. A,a1. A,a ,r('+'ya,r('+'ya
2. D&aa2. D&aa 9r&'8 ,(&t' / 9)a4'+9r&'8 ,(&t' / 9)a4'+
!. A,a y7 5a,at!. A,a y7 5a,at 95&&t&7at+95&&t&7at+ ,a5a 5a,a8,a5a 5a,a8
9 9r&'8 ,(&t' r&'8 ,(&t'
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Arjaty/ IMRK Arjaty/ IMRK 1212
S&A&EGI ED$#SI ISI#'S&A&EGI ED$#SI ISI#'
RENCANAREDUKSI RISIKO
Design Proses u/Meminimalkan
risikokegagalan
Design Proses u/Mengurangi
Dampak Kegagalan terjadi
pada pasien
Design Proses u/Meminimalkan
risikoKegagalan terjadi
Pada pasien
RISK POINS /
COMMON CAUSES
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Arjaty/ IMRK Arjaty/ IMRK 1!1!
C0(('&7 t0+ Pr()+''C0(('&7 t0+ Pr()+''
H&70 R&'8 ,r()+''+'H&70 R&'8 ,r()+''+' I5+t&3&+5 & t0+ *&t+rat4r+I5+t&3&+5 & t0+ *&t+rat4r+
I5+t&3&+5 y JCAHOI5+t&3&+5 y JCAHO
I5+t&3&+5 t0r(470 'a3+ty a*+rt'I5+t&3&+5 t0r(470 'a3+ty a*+rt'N+6 (r r+5+3&+5 ,r()+''N+6 (r r+5+3&+5 ,r()+''
Sta33 r+)(+5at&('Sta33 r+)(+5at&('
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Arjaty/ IMRK Arjaty/ IMRK 1"1"
IDENTIYING RISK PRONE SYSTEMIDENTIYING RISK PRONE SYSTEM
ar&a*+ &,4tar&a*+ &,4t
C(,*+ 'y't+'C(,*+ 'y't+'
N( 'ta5ar5&+5 'y't+'N( 'ta5ar5&+5 'y't+'
T&70t*y )(4,*+5 'y't+'T&70t*y )(4,*+5 'y't+'
Sy't+' 6&t0 t&70t t&+ )('tra&t'Sy't+' 6&t0 t&70t t&+ )('tra&t'
Sy't+' 6&t0 0&+rar)0&)a*Sy't+' 6&t0 0&+rar)0&)a*
$ i bl i t
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Arjaty/ IMRK Arjaty/ IMRK 1#1#
$ariable input
Pasien Penyakit berat
Penyakit penyerta Pernah mendapatkan pengobatan Usia
Pemberi Pelayanan Tingkat keterampilan Cara pendekatan
Proses Pelayanan harus dapat mengakomodasivariabilitas yang tdk dapat dihindarkan dan tidak dapatdikontrol ini.
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Arjaty/ IMRK Arjaty/ IMRK 1>1>
Complexitas
Pelayanan rumah sakit sangat kompleks Memerlukan beragam langkah yang sangat
mungkin berhadapan dengan kegagalan Semakin banyak langkah semakin besar
kemungkinan gagal Donald Berwick
! langkah "" error ! #
$% langkah "" error $$#
!&& langkah "" error '(#
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Arjaty/ IMRK Arjaty/ IMRK 11
Lack of Standardization
Sta5ar5 $ $$Sta5ar5 $ $$ ,r('+' t&5a8 5a,at +rja*a,r('+' t&5a8 5a,at +rja*a
'+'4a& 5+7a 0ara,a'+'4a& 5+7a 0ara,a
I5&-&54 ya7 +ja*a8a ,r('+' 0ar4'I5&-&54 ya7 +ja*a8a ,r('+' 0ar4'
+*a8'aa8a *a78a0 *a78a0 ya7 t+*a0+*a8'aa8a *a78a0 *a78a0 ya7 t+*a0
5&t+ta,8a '+)ara 8('&'t+5&t+ta,8a '+)ara 8('&'t+ ar&a&*&ta' &5&-&54a* 'a7at t&77& $ar&a&*&ta' &5&-&54a* 'a7at t&77& $
,+r*4 'ta5ar5 &' : SPO Para+t+r Pr(t(8(*,+r*4 'ta5ar5 &' : SPO Para+t+r Pr(t(8(*
Clinical PathwaysClinical Pathways 5a,at +ata'& ,+7ar40 5ar&5a,at +ata'& ,+7ar40 5ar&
-ar&a+* ya7 a5a.-ar&a+* ya7 a5a.
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Arjaty/ IMRK Arjaty/ IMRK 11
)eavily dependent on human *ntervention
K+t+r7at47a ya7 t&77& a8a &t+r-+'& '+'+(ra7
5a*a ,r('+' 5a,at +&4*8a -ar&a'&,+y&,a7a.
T&5a8 '+4a &,r(-&'a'& +r'&3at 4r48 5&8+a*
“ creating safety at the sharp end “
P+*ayaa 8+'+0ata 'a7at t+r7at47 ,a5a&t+r-+'& a4'&a
P+t47a' 0ar4' a,4 +7+5a*&8a '&t4a'& ya7t&5a8 t+r547a 5+& 8+'+*aata ,a'&+
Sa7at t+r7at47 ,a5a ,+5&5&8a 5a ,+*at&0aya7 +a5a& '+'4a& 5+7a t47a' 347'&ya
Tightly Coupled
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Arjaty/ IMRK Arjaty/ IMRK 11
Tightly Coupled
P+r,&5a0a *a78a0 5ar& '4at4 ,r('+' '+r&7 'a7at8+tat 8a5a7 ar4 5&'a5ar& t+rja5& ,+y&,a7a ,a5a*a78a0 ya7 t+*a0 *aj4t.
K+t+r*aata 5a*a '4at4 *a78a0 a8a +7a8&at8a7a774a ,a5a '+*4r40 ,r('+'
K+8+*&r4a 5a*a '4at4 *a78a0 a8a +7a8&at8a,+y&,a7a ,a5a *a78a0 +r&84t ( cascade of faillure )
K+'a*a0a &a'aya t+rja5& ,a5a 'aat ,+r,&5a0a *a78a0ata4 a5aya *a78a0 ya7 t+raa&8a
Hierarchical culture
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Arjaty/ IMRK Arjaty/ IMRK 2;2;
Hierarchical culture S4at4 ,r('+' a8a +70a5a,& r&'&8( 8+7a7a*a *+&0 t&77&
5a*a 4&t 8+rja 5+7a 45aya 90&rar8& 5&a5&78a 5+7a4&t 8+rja ya7 45ayaya +r(r&+ta'& ,a5a 9t+a.
Sta3 +77a +r8(4&8a'& +r8(*a(ra'& 'at4 5+7a ya7*a&
P+ra6at +77a +rtaya 8+,a5a 5(8t+r ata4 ,+t47a' 3ara'&t+ta7 +5&8a'& 5('&' '+rta +*++t ,+ra6ata *a&ya
B45aya 0&rar8& '+r&7 t+r)&,ta &'a*ya 5a*a ++t48a,+774aa (at -+r&3&8a'& *(8a'& ,++5a0a (*+0 t& +5a0.
Tata )ara +r8(4&8a'& atar 'ta3 5a*a ,r('+' ,+*ayaa8+'+0ata 'a7at ++t48a 0a'&*ya.
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Arjaty/ IMRK Arjaty/ IMRK 2121
*mplementing Sa+ety Cultures in Medicine ,hat ,e -earn by ,atching Physicians
imot!" #$ %o&' %enr" Po!l' #oel (art)eld
esiden di /amar Bedah 0 Commission
0 Suasana hierarki tinggi
0 /esalahan Teknis
esiden di M*CU 0 1mmission
Suasana hierarki lebih datar
0 /esalahan Pengambilan
/eputusan
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Arjaty/ IMRK Arjaty/ IMRK 2222
REDISAIN PROSESREDISAIN PROSES
Variable input Variable input
Complex Complex
NonstandarizedNonstandarized Tightly CoupledTightly Coupled
Dependent on humanDependent on human
interentioninterention
Time constraintsTime constraints Hierarchical cultureHierarchical culture
Decreasing ariability Decreasing ariability
Simplify Simplify
StandardizingStandardizing
Loosen coupling of processLoosen coupling of process !se technology !se technology
"ptimise #edundancy "ptimise #edundancy
$uilt in fail safe mechanism$uilt in fail safe mechanism
DocumentationDocumentation
%stablishing a culture of%stablishing a culture of
team&ork team&ork
FMEA
0at &' MEA 0at &' MEA
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Arjaty/ IMRK Arjaty/ IMRK 2!2!
0at &' MEA 0at &' MEA
A5a*a0 +t(5+ ,+ra&8a 8&+rja 57 +7&5+t&3&8a'& A5a*a0 +t(5+ ,+ra&8a 8&+rja 57 +7&5+t&3&8a'&
5a +)+7a0 ,(t+'& 8+7a7a*a '++*4 t+rja5&. Ha*5a +)+7a0 ,(t+'& 8+7a7a*a '++*4 t+rja5&. Ha*t+r'+4t 5&5+'a& 4t48 +&78at8a 8+'+*aatat+r'+4t 5&5+'a& 4t48 +&78at8a 8+'+*aata
,a'&+.,a'&+.
A5a*a0 ,r('+' ,r(a8t&3 5&aa 8+'a*a0a 5,t 5&)+7a0 A5a*a0 ,r('+' ,r(a8t&3 5&aa 8+'a*a0a 5,t 5&)+7a0
5&,r+5&8'&.5&,r+5&8'&. M+7at&'&,a'& 8+'a*a0a a8a +&&a*8a 5a,a8M+7at&'&,a'& 8+'a*a0a a8a +&&a*8a 5a,a8
4r484r48
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Arjaty/ IMRK Arjaty/ IMRK 2"2"
MEA MEA
0atF' t0+ ,(&t0atF' t0+ ,(&t
E*&&at&7 (r r+54)&7 t0+ r&'8 (3 t0+ 3a&*4r+ (5+'E*&&at&7 (r r+54)&7 t0+ r&'8 (3 t0+ 3a&*4r+ (5+'
)a r+'4*t & a)a r+'4*t & a
SAER AND MORE EICIENT SYSTEMSAER AND MORE EICIENT SYSTEM
3r( 60&)0 (t0 y(4 a5 y(4r ,at&+t' ++3&t.3r( 60&)0 (t0 y(4 a5 y(4r ,at&+t' ++3&t.
D+7a +7+*&&a'& ata4 +r+548'&D+7a +7+*&&a'& ata4 +r+548'&
r&'&8( 8+7a7a*a a8a +70a'&*8a '4at4r&'&8( 8+7a7a*a a8a +70a'&*8a '4at4
SISTEM YANG AMAN DAN LEBIH EISIENSISTEM YANG AMAN DAN LEBIH EISIEN
BAGI RS DAN PASIENBAGI RS DAN PASIEN..
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Arjaty/ IMRK Arjaty/ IMRK 2#2#
!at is Failure Mode and Effect Analysis
/FMEA0 1
A t((* t( :$ Aa*y+ a ,r()+'' t( '++ 60+r+ &t &' *&8+*y t( 3a&*
$S++ 0(6 )0a7+' y(4 ar+ )('&5+r&7 &70t a33+)tt0+ 'a3+ty (3 t0+ ,r()+''
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Arjaty/ IMRK Arjaty/ IMRK 2>2>
a&*4r+ M(5+ a5 E33+)t' Aa*y'&'a&*4r+ M(5+ a5 E33+)t' Aa*y'&'
1. D+3&+ 3a&*4r+ (5+.1. D+3&+ 3a&*4r+ (5+.
2. I5+t&3y )a4'+ (3 3a&*4r+.2. I5+t&3y )a4'+ (3 3a&*4r+.
!. I5+t&3y +33+)t' (3 3a&*4r+!. I5+t&3y +33+)t' (3 3a&*4r+
". C(rr+)t&-+ a)t&(.". C(rr+)t&-+ a)t&(.
60at )(4*5 7( 6r(7
60y 6(4*5 t0+ 3a&*4r+
0a,,+
60at 6(4*5 + t0+
)('+=4+)+' (3 +a)03a&*4r+
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Arjaty/ IMRK Arjaty/ IMRK 22
MEA T+r&(*(7yMEA T+r&(*(7y
Pr()+'' MEAPr()+'' MEA $ C(54)t a MEA ( a$ C(54)t a MEA ( a,r()+'' t0at &' a*r+a5y & ,*a)+,r()+'' t0at &' a*r+a5y & ,*a)+
D+'&7 MEAD+'&7 MEA C(54)t a MEA +3(r+ a C(54)t a MEA +3(r+ a
,r()+'' &' ,4t &t( ,*a)+,r()+'' &' ,4t &t( ,*a)+ I,*++t&7 a +*+)tr(&) +5&)a* r+)(r5' (rI,*++t&7 a +*+)tr(&) +5&)a* r+)(r5' (r
(t0+r a4t(at+5 'y't+'(t0+r a4t(at+5 'y't+'P4r)0a'&7 +6 +=4&,+tP4r)0a'&7 +6 +=4&,+tR+5+'&7&7 E+r7+)y R(( O,+rat&7 R((R+5+'&7&7 E+r7+)y R(( O,+rat&7 R((
*((r +t).*((r +t).
FAI($E M'DE AND EFFE%&S ANA()SISFAI($E M'DE AND EFFE%&S ANA()SIS
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Arjaty/ IMRK Arjaty/ IMRK 22
FAI($E M'DE AND EFFE%&S ANA()SISFAI($E M'DE AND EFFE%&S ANA()SIS
FAI($E /F0FAI($E /F0 : 0+ a 'y't+ (r ,art (3 a 'y't+: 0+ a 'y't+ (r ,art (3 a 'y't+
,+r3(r' & a 6ay t0at &' (t,+r3(r' & a 6ay t0at &' (t&t+5+5 (r 5+'&ra*+&t+5+5 (r 5+'&ra*+
MODE ?M@MODE ?M@ : T0+ 6ay (r a+r & 60&)0: T0+ 6ay (r a+r & 60&)0
'(+t0&7 '4)0 a' a 3a&*4r+ )a'(+t0&7 '4)0 a' a 3a&*4r+ )a
0a,,+. a&*4r+ (5+ &' t0+0a,,+. a&*4r+ (5+ &' t0+
a+r & 60&)0 '(+t0&7 )aa+r & 60&)0 '(+t0&7 )a
3a&*.3a&*.
EFFE%&S /E0EFFE%&S /E0 : T0+ r+'4*t' (r )('+=4+)+' (3 a: T0+ r+'4*t' (r )('+=4+)+' (3 a
3a&*4r+ (5+3a&*4r+ (5+
Analysis /A0Analysis /A0 : T0+ 5+ta&*+5 +a&at&( (3 t0+: T0+ 5+ta&*+5 +a&at&( (3 t0++*++t' (r 'tr4)t4r+ (3 a ,r()+''+*++t' (r 'tr4)t4r+ (3 a ,r()+''
0 0 *5 & t&0 0 *5 & t&
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Arjaty/ IMRK Arjaty/ IMRK 22
Ca ,r+-+t +rr(r' +ar&''+'Ca ,r+-+t +rr(r' +ar&''+' ,r(t+)t&7,r(t+)t&7,at&+t' 3r( 0ar.,at&+t' 3r( 0ar.
CaCa &)r+a'+ t0+ +33+)t&-++'' +33&)&+)y (3&)r+a'+ t0+ +33+)t&-++'' +33&)&+)y (3
,r()+'',r()+''
Ta8&7 a ,r(a)t&-+ a,,r(a)0 t( ,at&+t 'a3+ty a*'(Ta8&7 a ,r(a)t&-+ a,,r(a)0 t( ,at&+t 'a3+ty a*'(
a8+' 7((5 4'&+'' '+'+ & a 0+a*t0 )ar+a8+' 7((5 4'&+'' '+'+ & a 0+a*t0 )ar+
+-&r(+t t0at &' &)r+a'&7*y 3a)&7 5+a5' 3r(+-&r(+t t0at &' &)r+a'&7*y 3a)&7 5+a5' 3r(
)('4+r' r+74*at(r' ,ay+r' t( )r+at+ )4*t4r+)('4+r' r+74*at(r' ,ay+r' t( )r+at+ )4*t4r+
3()4'+5 (3()4'+5 ( r+54)&7 r&'8 &)r+a'&7 a))(4ta&*&tyr+54)&7 r&'8 &)r+a'&7 a))(4ta&*&ty
0y '0(4*5 y (r7a&at&(0y '0(4*5 y (r7a&at&(
)(54)t a MEA )(54)t a MEA
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Arjaty/ IMRK Arjaty/ IMRK !;!;
MEA 0a' ++ ar(45 3(r (-+r !; y+ar'MEA 0a' ++ ar(45 3(r (-+r !; y+ar'R+)+t*y 7a&+5 6&5+',r+a5 a,,+a* (4t'&5+ (3R+)+t*y 7a&+5 6&5+',r+a5 a,,+a* (4t'&5+ (3
'a3+ty ar+a'a3+ty ar+a
N+6 t( 0+a*t0)ar+N+6 t( 0+a*t0)ar+r+=4+t*y 4'+5 r+*&a&*&ty 'y't+ 'a3+tyr+=4+t*y 4'+5 r+*&a&*&ty 'y't+ 'a3+ty
aa*y'&' t+)0&=4+'aa*y'&' t+)0&=4+'
L(7 &54'try tra)8 r+)(r5L(7 &54'try tra)8 r+)(r5 : A-&at&( N4)*+ar: A-&at&( N4)*+ar
,(6+r A+r(',a)+ C0+&)a* ,r()+'',(6+r A+r(',a)+ C0+&)a* ,r()+''&54'tr&+' A4t((&-+&54'tr&+' A4t((&-+
0+r+ 5&5 MEA )(+ 3r( 0+r+ 5&5 MEA )(+ 3r(
St+, O+St+, O+
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Arjaty/ IMRK Arjaty/ IMRK !1!1
St+, O+St+, O+S+*+)t a ,r()+'' t( +-a*4at+ 6&t0 MEA
St+, T6(St+, T6(
R+)r4&t a 4*t& 5&')&,*&ary t+a
B+ '4r+ t( &)*45+ +-+ry(+
60( &' &-(*-+5 at ay ,(&t & t0+ ,r()+''
Ha-+ t0+ t+a ++t t(7+t0+r t( *&'t a** t0+ 't+,'
& t0+ ,r()+''
N4+r +-+ry 't+, & t0+ ,r()+'' a5 + a'N4+r +-+ry 't+, & t0+ ,r()+'' a5 + a'
',+)&3&) a' ,(''&*+',+)&3&) a' ,(''&*+
St T0St+, T0r++
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Arjaty/ IMRK Arjaty/ IMRK !2!2
St+, T0r++St+, T0r++
Ha-+ t0+ t+a *&'t 3a&*4r+ (5+' a5 +33+)tHa-+ t0+ t+a *&'t 3a&*4r+ (5+' a5 +33+)t
L&'t ayt0&7 t0at )(4*5 7( 6r(7 &)*45&7 &(rL&'t ayt0&7 t0at )(4*5 7( 6r(7 &)*45&7 &(ra5 rar+ ,r(*+'a5 rar+ ,r(*+'
I5+t&3y a** ,(''&*+ )a4'+' 3(r +a)0 3a&*4r+ (5+I5+t&3y a** ,(''&*+ )a4'+' 3(r +a)0 3a&*4r+ (5+
For eac! failure mode, determine t!e potential effect on t!e patient
(ikeli!ood of occurrence(ikeli!ood of detectionSeverity
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Arjaty/ IMRK Arjaty/ IMRK !!!!
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Arjaty/ IMRK Arjaty/ IMRK !"!"
St+, 3(4r St+, 3(4r
Pr&(r&t&+ 3a&*4r+ (5+
St+, 3&-+St+, 3&-+
Ha-+ t0+ t+a *&'t +33+)t (3 3a&*4r+ (5+
For eac! failure mode, determine t!e potential cause on t!e patient
(ikeli!ood of occurrence
(ikeli!ood of detectionSeverity
St+, S&St+, S&
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Arjaty/ IMRK Arjaty/ IMRK !#!#
St+, S&St+, S& REDESIGN PROCESS
D+t+r&+ 60&)0 3a&*4r+' t( 6(r8 ( Ca*)4*at+ t0+ RISK PRIORITY NUMBER ?RPN@:?RPN@:
L&8+*&0((5 S+-+r&ty D+t+)t&(L&8+*&0((5 S+-+r&ty D+t+)t&(
I5+t&3y t0+ 3a&*4r+ (5+' 6&t0 t0+ t(, 1; RPN'I5+t&3y t0+ 3a&*4r+ (5+' 6&t0 t0+ t(, 1; RPN'
&A#E A DEE- 2EA&3&A#E A DEE- 2EA&3
C(54)t a *&t+rat4r+ '+ar)0 t(C(54)t a *&t+rat4r+ '+ar)0 t( 7at0+r r+*+-at &3(rat&(7at0+r r+*+-at &3(rat&(
3r( t0+ ,r(3+''&(a* *&t+rat4r+3r( t0+ ,r(3+''&(a* *&t+rat4r+. D( (t r+&-+t t0+ 60++*. D( (t r+&-+t t0+ 60++*
N+t6(r8 6&t0 )(**+a74+'N+t6(r8 6&t0 )(**+a74+'
E%'MMI& &' '$& 'F &3E 2'4 &3IN#INGE%'MMI& &' '$& 'F &3E 2'4 &3IN#ING
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Arjaty/ IMRK Arjaty/ IMRK !>!>
St+, S+-+St+, S+-+
Aa*y+ a5 t+'t t0+ +6 ,r()+'' Aa*y+ a5 t+'t t0+ +6 ,r()+''U'+ RPN' t( ,*a &,r(-++t +33(rt'U'+ RPN' t( ,*a &,r(-++t +33(rt'
a&*4r+ (5+' 6&t0 0&70 RPN' ar+ 4'4a**y t0+ ('t &,(rtata&*4r+ (5+' 6&t0 0&70 RPN' ar+ 4'4a**y t0+ ('t &,(rtat,art' (3 t0+ ,r()+'' t( )()+trat+ &,r(-++t +33(rt'.,art' (3 t0+ ,r()+'' t( )()+trat+ &,r(-++t +33(rt'.
T0+ t+a a7a& )(,*+t+' steps 5 ?5&a7ra t0+ ,r()+''@step ?ra&'t(r ,(t+t&a* 3a&*4r+ (5+' 5+t+r&+ t0+&r+33+)t@ a5 step 6 ?,r&(r&t&+ 3a&*4r+ (5+'@ (3 t0+ MEA,r()+''
T0+ t0+ t+a '0(4*5 )a*)4*at+ a +6 )r&t&)a*&ty &5+ ?CI@ (r
RPN.
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Arjaty/ IMRK Arjaty/ IMRK !!
St+, E&70tSt+, E&70t
I,*++t (&t(r t0+ r+5+'&7+5 ,r()+''
D+'&7 &,r(-++t' '0(4*5 r&7 r+54)t&(& t0+ CI / RPN.
E78 9 : ;9< reduction 1
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Arjaty/ IMRK Arjaty/ IMRK !!
FMEA 3FMEA 3FME%A=
(ANG#A35 FMEA, 3FMEA, 3FME%A= (ANG#A35 FMEA, 3FMEA, 3FME%A=
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Arjaty/ IMRK Arjaty/ IMRK !!
FMEA
'riginal
3FMEA
2y 8 +A N%-S
3FME%A=
2y IM#
11 S+*+)t a 0&70 r&'8 ,r()+''
a''+*+ a t+a
D+3&+ t0+ HMEAT(,&)
S+*+)t a 0&70 r&'8 ,r()+''
a''+*+ a t+a
22 D&a7ra t0+ ,r()+'' A''+*+ t0+ T+a D&a7ra t0+ ,r()+''
!! Bra&'t(r ,(t+t&a* failure modes 5+t+r&+ t!eir effects
/- 4 S 4 De0
Gra,0&)a**y 5+')r&+t0+ Pr()+''
Bra&'t(r ,(t+t&a* failure modes
/- 4 S0 7 # 4 De, 2ands
"" Pr&(r&t&+ 3a&*4r+ (5+' C(54)t a Haar5 Aa*y'&'
Pr&(r&t&+ 3a&*4r+ (5+'
## I5+t&3y root causes (3 3a&*4r+ (5+'
/- 4 S 4 De0
A)t&(' O4t)(+M+a'4r+'
I5+t&3y root causes (3 3a&*4r+ (5+'
/- 4 S0 7 # 4 De, 2ands
>> EDESIGN &3E -'%ESS %A(%$(A&E &'&A( -N
Aa*y+ t+'t t0+ +6 ,r()+'' EDESIGN &3E -'%ESS
I,*++t (&t(r t0+ r+5+'&7+5,r()+''
Aa*y+ t+'t t0+ +6 ,r()+''
I,*++t (&t(r t0+ r+5+'&7+5,r()+''
A&ING S)S&EM/Modified >y IM#0
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Arjaty/ IMRK Arjaty/ IMRK ";";
ating -ro>a>ilitas
/-0
Severity
/S0
#ontrol
/#0
Deteksi
/D0
? emote Minor effect Easy %ertain to detect
5 (o@ likeli!ood Moderate effect Mpderate Easy 3ig! likeli!ood
Moderate
likeli!ood
Minor inury Moderate
difficult
Moderate
likeli!ood
6 3ig! likeli!ood Maor inury Difficult (o@ likeli!ood
; %ertain to occur %atastrop!ic effect Bterminal inury, deat!
Almost certainnot to detect
isk -riority Num>er /-N0 B %riticaly Inde7 /%I0 C /- 7 S0 7 # 7 D
!at is 3FMEA 1!at is 3FMEA 1M difi d > +A N%-SModified >y +A N%-S
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Arjaty/ IMRK Arjaty/ IMRK "1"1
Modified >y +A N%-SModified >y +A N%-S
()4' ( ,r+-+t&7 5+3+)t' +0a)&7 'a3+ty &)r+a'+ ,('&t&-+
(4t)(+ a5 &)r+a'+ ,at&+t 'at&'3a)t&(
T0+ (j+)t&-+ &' t( *((8 3(r a** 6ay' 3(r ,r()+'' (r ,r(54)t )a3a&*
T0+ 3a(4' =4+'t&( : 90at &' )(4*5 0a,,+ N(t 90at 5(+'0a,,+
Hyr&5 ,r(',+)t&-+ aa*y'&' (5+* )(&+' )()+,t' :
MEA ?a&*4r+ M(5+ a5 E33+)t' Aa*y'&'@ HACCP ?Haar5 Aa*y'&' Cr&t&)a* C(tr(* P(&t'@
RCA ?R((t Ca4'+ Aa*y'&'@
HMEA C(,(+t' a5 T0+&r Or&7&'HMEA C(,(+t' a5 T0+&r Or&7&'
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Arjaty/ IMRK Arjaty/ IMRK "2"2
%oncepts%oncepts 3FMEA3FMEA FMEAFMEA 3A%%-3A%%- %A%A
&eam mem>ers!ip&eam mem>ers!ip ++ ++ ++
Diagramming processDiagramming process ++ ++ ++
Failure mode * causesFailure mode * causes ++ ++
3a"ard Scoring Matri73a"ard Scoring Matri7 ++ ++
Severity * -ro>a>ilitySeverity * -ro>a>ilityDefinitionsDefinitions
++ ++
Decision &reeDecision &ree ++ ++
Actions * 'utcomesActions * 'utcomes ++ ++
esponsi>le person *esponsi>le person *managementmanagementconcurrenceconcurrence
++ ++
)2CCP )a3ard 2nalysis Critical Control Point
&IME (INE AND &EAM A%&I+I&IES
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Arjaty/ IMRK Arjaty/ IMRK "!"!
Pr+++t&7 I5+t&3y T(,&) a5 (t&-y t0+ t+a ?St+, 1 2@
1't t+a ++t&7 D&a7ra t0+ ,r()+'' &5+t&3y '4,r()+'' -+r&3y t0+ ')(,+
2r5 t+a ++t&7 &'&t t0+ 6(r8'&t+ t( ('+r-+ t0+ ,r()+'' -+r&3y t0at a** ,r()+''
'4,r()+'' 't+,' ar+ )(rr+)t ?St+, !@! r5 t+a ++t&7 Bra&'t(r&7 3a&*4r+ (5+' a''&7 &5&-&54a* t+a ++r' t( consult
@it! process users /Step 0
"r5 t+a ++t&7 I5+t&3y 3a&*4r+ (5+' )a4'+' a''&7 &5&-&54a* t+a ++r' t( consult@it! process users for additional input /Step 0
#t0 t+a ++t&7 Tra'3+r M Ca4'+' t( t0+ HMEA (r8'0++t ?St+,!@. B+7& t0+ 0aar5
aa*y'&' ?St+, "@I5+t&3y )(rr+)t&-+ a)t&(' a5 a''&7 3(**(6 4, r+',('&&*&t&+' ?St+, #@
>t0t0 t0.η t+a++t&7 ,*4' 1
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Arjaty/ IMRK Arjaty/ IMRK "#"#
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St !St !
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Arjaty/ IMRK Arjaty/ IMRK ">">
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D+-+*(, a5 -+r&3y t0+ 3*(6 D&a7raD+-+*(, a5 -+r&3y t0+ 3*(6 D&a7ra ?t0&' &' a?t0&' &' a,r()+'' -' )0r((*(7&)a* 5&a7ra@,r()+'' -' )0r((*(7&)a* 5&a7ra@ C('+)4t&-+*y 4+r +a)0 ,r()+''C('+)4t&-+*y 4+r +a)0 ,r()+'' 't+, &5+t&3&+5't+, &5+t&3&+5
& t0+ ,r()+'' 3*(6 5&a7ra& t0+ ,r()+'' 3*(6 5&a7ra I3 t0+ ,r()+'' &' )(,*+I3 t0+ ,r()+'' &' )(,*+ &5+t&3y t0+ ar+a (3 t0+&5+t&3y t0+ ar+a (3 t0+
,r()+'' t( 3()4' (,r()+'' t( 3()4' ( ?aa7+a*+ &t+@?aa7+a*+ &t+@ I5+t&3y a** '4 ,r()+''+' 45+r +a)0 *()8 (3 t0&'I5+t&3y a** '4 ,r()+''+' 45+r +a)0 *()8 (3 t0&'
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Arjaty/ IMRK Arjaty/ IMRK ""
St+, "St+, "
L&'tL&'t a&*4r+ (5+'a&*4r+ (5+'D+t+r&+D+t+r&+ S+-+r&ty Pr(a&*&tyS+-+r&ty Pr(a&*&ty
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Arjaty/ IMRK Arjaty/ IMRK ""
St+, #St+, #
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ORM TOOLSORM TOOLS
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Arjaty/ IMRK Arjaty/ IMRK ""
ORM TOOLSORM TOOLS
(r(r(r8'0++t'(r8'0++t'
Haar5 S)(r&7 atr&Haar5 S)(r&7 atr&
D+)&'&( tr++D+)&'&( tr++
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Arjaty/ IMRK Arjaty/ IMRK #;#;
P&*&0 Pr('+' +r&'&8( t&77& ya7 a8a 5&aa*&'a.P&*&0 Pr('+' +r&'&8( t&77& ya7 a8a 5&aa*&'a.
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Ta77a* 5&4*a& Ta77a* '+*+'a& Ta77a* 5&4*a& Ta77a* '+*+'a&
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Arjaty/ IMRK Arjaty/ IMRK #2#2
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Arjaty/ IMRK Arjaty/ IMRK #!#!
ANA(ISIS 3AHAD (E+E( DAM-A#JANA(ISIS 3AHAD (E+E( DAM-A#JDAMPAK DAMPAK MINORMINOR
11MODERATMODERAT
22
MAYOR
3
KATASTROPIK
4
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Arjaty/ IMRK Arjaty/ IMRK #"#"
Kegagalan yang tidakKegagalan yang tidak
mengganggu Prosesmengganggu Proses
pelayanan kepada Pasien pelayanan kepada Pasien
Kegagalan dapatKegagalan dapat
mempengaruhi prosesmempengaruhi proses
dan menimbulkandan menimbulkan
kerugian ringankerugian ringan
Kegagalan menyebabkankerugian berat
Kegagalan menyebabkan kerugian besar
PasienPasien Tidak ada cedera,Tidak ada cedera,Tidak ada perpanjanganTidak ada perpanjangan
hari rawathari rawat
Cedera ringanCedera ringanAda PerpanjanganAda Perpanjangan
hari rawathari rawat
Cedera luas / beratPerpanjangan hari rawatlebih lama (+ ! bln"#erkurangnya $ungsi permanen organ tubuh(sensorik / motorik / psikcologik / intelektual"
Kematian Kehilangan $ungsi tubuhsecara permanent (sensorik,motorik, psikologik atauintelektual" mis % &perasi pada bagian atau pada pasien yang salah, Tertukarnya bayi
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Terjadi pada !' sta$ Terjadi pada !' sta$
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kec kerjakec kerja % ') sta$ % ') sta$
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kecelakaan kerja pada)'* sta$
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ANA(ISISANA(ISIS HAZARDHAZARD J(E+E( -'2A2I(I&ASJ J(E+E( -'2A2I(I&ASJ
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Arjaty/ IMRK Arjaty/ IMRK ####
E!EE!E DESKRIPSIDESKRIPSI "ONTO#"ONTO#
44 Se$ingSe$ing (Frequent)(Frequent) #a%&i$ se$ing %un'ul (ala% )a*tu +ang#a%&i$ se$ing %un'ul (ala% )a*tu +ang$elati,e sing*at -%ung*in te$ja(i .e.e$a&a$elati,e sing*at -%ung*in te$ja(i .e.e$a&a
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22 a$anga$ang (Uncommon)(Uncommon) Ke%ung*inan a*an %un'ulKe%ung*inan a*an %un'ul
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(Remote)(Remote)a$ang se*ali te$ja(i -(a&at te$ja(i (ala% a$ang se*ali te$ja(i -(a&at te$ja(i (ala%
sa%&ai 35 ta/un0sa%&ai 35 ta/un0
3AHAD S%'E
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Arjaty/ IMRK Arjaty/ IMRK #>#>
TIN6KAT 7A#AYATIN6KAT 7A#AYA
KATASTROPIK KATASTROPIK 44
MAYOR MAYOR 33
MODERATMODERAT22
MINOR MINOR 11
SERIN6SERIN6
441818 1212 99 44
KADAN6KADAN6
33 1212 88 33
ARAN6ARAN6
2299 88 44 22
#AMPIR TIDAK#AMPIR TIDAK
PERNA#PERNA#11
44 33 22 11
Decision &reeDecision &ree
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Arjaty/ IMRK Arjaty/ IMRK ##
.oes this haard in0ol0e a
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Arjaty/ IMRK Arjaty/ IMRK ##
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Arjaty/ IMRK Arjaty/ IMRK ##
C(t(0 8a'4' 2C(t(0 8a'4' 2PROSES KEGIATAN PAGI HARI MENUJU TEMPAT KERJA
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Arjaty/ IMRK Arjaty/ IMRK >;>;
PROSES KEGIATAN PAGI HARI MENUJU TEMPAT KERJA
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Arjaty/ IMRK Arjaty/ IMRK >1>1
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Arjaty/ IMRK Arjaty/ IMRK >2>2
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Arjaty/ IMRK Arjaty/ IMRK >!>!
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Arjaty/ IMRK Arjaty/ IMRK >">"
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Arjaty/ IMRK Arjaty/ IMRK >#>#
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Arjaty/ IMRK Arjaty/ IMRK >>>>
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Arjaty/ IMRK Arjaty/ IMRK >>
(EM2A AM#D / F'M 3FMEA 0
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Arjaty/ IMRK Arjaty/ IMRK >>
#egagalan 8#egagalan 8
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AM#D B 3FMEA
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Arjaty/ IMRK Arjaty/ IMRK >>
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Arjaty/ IMRK Arjaty/ IMRK ;;
PrioritasPrioritas
risikorisiko
Total P4 Total P4
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Arjaty/ IMRK Arjaty/ IMRK 11
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TINGKATKAN KOMUNIKASITINGKATKAN KOMUNIKASI
EEKTIEEKTI
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Arjaty/ IMRK Arjaty/ IMRK 22
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Arjaty/ IMRK Arjaty/ IMRK !!
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Arjaty/ IMRK Arjaty/ IMRK ""
JANGAN GUNAKAN SINGKATANJANGAN GUNAKAN SINGKATAN
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Arjaty/ IMRK Arjaty/ IMRK ##
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Arjaty/ IMRK Arjaty/ IMRK >>
2E(AA DAI -ENGA(AMAN
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Arjaty/ IMRK Arjaty/ IMRK
KESIMPULANKESIMPULANBuilding a safe healthcareBuilding a safe healthcare
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