Langkah Ke 7-Cegah Cedera Melalui Implementasi Keselamatan Pasien

8/16/2019 Langkah Ke 7-Cegah Cedera Melalui Implementasi Keselamatan Pasien

1/79


2/79

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


3/79

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


4/79

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;


6/79

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'&


7/79

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'&'


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.


8/79


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&.


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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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


10/79

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@


11/79


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'


12/79


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


13/79

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&('


14/79

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


15/79

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.


16/79

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 '(#


17/79


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.


18/79


)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


19/79


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


20/79

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.


21/79


*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


22/79


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


23/79

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


24/79

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..


25/79

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()+''


26/79

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+


27/79


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


28/79


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&


29/79


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


30/79

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+


31/79

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++


32/79

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


33/79

Arjaty/ IMRK Arjaty/ IMRK !!!!


34/79

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&


35/79

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


36/79

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.


37/79


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


38/79


FMEA 3FMEA 3FME%A=

(ANG#A35 FMEA, 3FMEA, 3FME%A= (ANG#A35 FMEA, 3FMEA, 3FME%A=


39/79


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


40/79

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


41/79

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&'


42/79

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


43/79

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

A''&7 t+a ++r' t( 3(**(6 4, &5&-&54a* )0ar7+5 6&t0 ta8&7 )(rr+)t&-+a)t&(

η t+a ++t&7 ,*4' 2 R+3&+ )(rr+)t&-+ a)t&(' a'+5 ( 3++5a)8

η t+a ++t&7 ,*4' ! T+'t t0+ ,r(,('+5 )0a7+'

η t+a ++t&7 ,*4' " M++t 6&t0 T(, Maa7++t t( (ta& a,,r(-a* 3(r a** a)t&('

P('tt+a ++t&7 T0+ a5-&'(r (r 0&'/ 0+r 5+'&7++ 3(**(6 4, 4t&* a** a)t&(' ar+ )(,*+t+5

(ANG#A3(ANG#A3

ANA ISIS M'D$S #EGAGA AN * DAM-A# /AM#D0=


44/79

1.1. T+ta,8a T(,&8 AMKDT+ta,8a T(,&8 AMKD2. B+t48 T&2. B+t48 T&!. Gaar8a A*4r Pr('+'!. Gaar8a A*4r Pr('+'

". B4at Haar5 Aa*y'&'". B4at Haar5 Aa*y'&'

#. T&5a8a 5a P+7484ra O4t)(+#. T&5a8a 5a P+7484ra O4t)(+

ANA(ISIS M'D$S #EGAGA(AN * DAM-A# /AM#D0=

/3EA(&3%AE FAI($E M'DE EFFE%& AND ANA()SIS0

/3FMEA0

2y 8 +A N%-S

St 1St 1


45/79

Arjaty/ IMRK Arjaty/ IMRK "#"#

St+, 1St+, 1

D+3&+ t0+ S)(,+ (3 HMEA a*(7 6&t0 a )*+arD+3&+ t0+ S)(,+ (3 HMEA a*(7 6&t0 a )*+ar5+3&&t&( (3 t0+ ,r()+'' t( + 't45&+55+3&&t&( (3 t0+ ,r()+'' t( + 't45&+5

St+, 2St+, 2

M4*t&5&'&,*&ary t+a 6&t0 S4j+)t att+rM4*t&5&'&,*&ary t+a 6&t0 S4j+)t att+r

+,+rt?'@ ,*4' a5-&'(r +,+rt?'@ ,*4' a5-&'(r

St !St !


46/79

Arjaty/ IMRK Arjaty/ IMRK ">">

St+, !St+, !

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&'

3*(6 5&a7ra3*(6 5&a7ra. C('+)4t&-+*y *+tt+r t0+'+ '4 't+,'. C('+)4t&-+*y *+tt+r t0+'+ '4 't+,' Cr+at+ a 3*(6 5&a7ra )(,('+5 (3 t0+ '4Cr+at+ a 3*(6 5&a7ra )(,('+5 (3 t0+ '4

,r()+''+',r()+''+'

St "St+, "


47/79


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

U'+ t0+U'+ t0+ D+)&'&( tr++D+)&'&( tr++

L&'t a** a&*4r+ (5+L&'t a** a&*4r+ (5+ )a4'+')a4'+'

St #St+, #


48/79


St+, #St+, #

D+)&5+ t( 9D+)&5+ t( 9E*&&at+ C(tr(* (r 9A))+,tE*&&at+ C(tr(* (r 9A))+,t t0+ 3a&*4r+t0+ 3a&*4r+(5+ )a4'+(5+ )a4'+

D+')r&+ aD+')r&+ a a)t&( 3(r +a)0 3a&*4r+ (5+ )a4'+a)t&( 3(r +a)0 3a&*4r+ (5+ )a4'+ t0att0at6&** +*&&at+ (r )(tr(* &t.6&** +*&&at+ (r )(tr(* &t.

I5+t&3yI5+t&3y (4t)(+ +a'4r+'(4t)(+ +a'4r+' t0at 6&** + 4'+5 t(t0at 6&** + 4'+5 t(aa*y+ a5 t+'t t0+ r+$5+'&7+5 ,r()+''aa*y+ a5 t+'t t0+ r+$5+'&7+5 ,r()+''

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ORM TOOLSORM TOOLS


49/79


ORM TOOLSORM TOOLS

(r(r(r8'0++t'(r8'0++t'

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P&*&0 P & &8 t& & 8 5& *&P&*&0 Pr('+' +r&'&8( t&77& ya7 a8a 5&aa*&'a


50/79

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&


51/79


52/79

Arjaty/ IMRK Arjaty/ IMRK #2#2


53/79

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


54/79

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

PengunjuPengunju

ngng

Tidak ada cederaTidak ada cederaTidak ada penangananTidak ada penangananTerjadi pada !' orgTerjadi pada !' org

pengunjung pengunjung

Cedera ringanCedera ringan Ada PenangananAda Penanganan

ringanringan Terjadi pada ')Terjadi pada ')

pengunjung pengunjung

Cedera luas / berat Perlu dirawat Terjadi pada ) '* orang pengunjung

KematianTerjadi pada * orang pengunjung

Staf:Staf: Tidak ada cederaTidak ada cederaTidak ada penangananTidak ada penanganan

Terjadi pada !' sta$ Terjadi pada !' sta$

Tidak ada kerugianTidak ada kerugian

waktu / keckerjawaktu / keckerja

Cedera ringanCedera ringan Ada Penanganan /Ada Penanganan /

TindakanTindakan K K ehilangan waktu /ehilangan waktu /

kec kerjakec kerja % ') sta$ % ') sta$

Cedera luas / berat Perlu dirawatKehilangan waktu /

kecelakaan kerja pada)'* sta$

KematianPerawatan * sta$

FasilitasFasilitas

KesKes Kerugian ! ,,Kerugian ! ,,

atau tanpa menimbulkanatau tanpa menimbulkan

dampak terhadap pasiendampak terhadap pasien

KerugianKerugian

!,, '!,, '

!,,!,,

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Kerugian -,,

ANA(ISISANA(ISIS HAZARDHAZARD J(E+E( -'2A2I(I&ASJ J(E+E( -'2A2I(I&ASJ


55/79

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

*ali (ala% 1 ta/un0*ali (ala% 1 ta/un0

33 Ka(ang*a(angKa(ang*a(ang

(Occasional)(Occasional)

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-(a&at te$ja(i .e.ea$a&a *ali (ala% 1 sa%&ai-(a&at te$ja(i .e.ea$a&a *ali (ala% 1 sa%&ai2 ta/un02 ta/un0

22 a$anga$ang (Uncommon)(Uncommon) Ke%ung*inan a*an %un'ulKe%ung*inan a*an %un'ul

-(a&at te$ja(i (ala% 2 sa%&ai ta/un0-(a&at te$ja(i (ala% 2 sa%&ai ta/un0

11 #a%&i$ Ti(a* Pe$na/#a%&i$ Ti(a* Pe$na/

(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


56/79

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


57/79


.oes this haard in0ol0e a

su$$icient likelihood o$occurrence and se0erity to

warrant that it be controlled1

(#a;a$( s'


58/79



59/79


C(t(0 8a'4' 2C(t(0 8a'4' 2PROSES KEGIATAN PAGI HARI MENUJU TEMPAT KERJA


60/79

Arjaty/ IMRK Arjaty/ IMRK >;>;

PROSES KEGIATAN PAGI HARI MENUJU TEMPAT KERJA


61/79

Arjaty/ IMRK Arjaty/ IMRK >1>1


62/79

Arjaty/ IMRK Arjaty/ IMRK >2>2


63/79

Arjaty/ IMRK Arjaty/ IMRK >!>!


64/79

Arjaty/ IMRK Arjaty/ IMRK >">"


65/79

Arjaty/ IMRK Arjaty/ IMRK >#>#


66/79

Arjaty/ IMRK Arjaty/ IMRK >>>>


67/79


(EM2A AM#D / F'M 3FMEA 0

AM#D (angka! 6 Analisis 3a"ardAM#D (angka! 6 Analisis 3a"ard AM#D (angka! ; Identifikasi &indakan * 'utcomeAM#D (angka! ; Identifikasi &indakan * 'utcome

M'D$SM'D$S

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&i d k B&i d k B


68/79


#egagalan 8#egagalan 8

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Mr..Mr.. Y+'Y+'

HFMEA : Healthcare Failure Mode Effect and Analysis

AM#D B 3FMEA


69/79


Pr('+' *aa

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70/79

Arjaty/ IMRK Arjaty/ IMRK ;;

PrioritasPrioritas

risikorisiko

Total P4 Total P4

P1S5SP1S5S-2M2-2M2

6ailure6ailure

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9;9


71/79


1.1. I5+t&3&8a'& ,a'&+ 5+7a +ar I5+t&3&8a'& ,a'&+ 5+7a +ar

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International Patient Safety GoalsInternational Patient Safety Goals

TINGKATKAN KOMUNIKASITINGKATKAN KOMUNIKASI

EEKTIEEKTI


72/79


EEKTIEEKTI

)andover

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&ingkatkan keamanan untuk&ingkatkan keamanan untuk pem>erianpem>erian

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73/79


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74/79


JANGAN GUNAKAN SINGKATANJANGAN GUNAKAN SINGKATAN


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76/79


2E(AA DAI -ENGA(AMAN


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KESIMPULANKESIMPULANBuilding a safe healthcareBuilding a safe healthcare


78/79


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Documents

Langkah Ke 7-Cegah Cedera Melalui Implementasi Keselamatan Pasien