LAPORAN

FAILURE MODE EFFECT ANALYSIS (FMEA)

IDENTIFIKASI DAN PENGURANGAN RISIKO

DALAM PELAYANAN LABORATORIUM
DI RS PKU MUHAMMADIY
MUHAMMAD IYAH
AH YOGYAKART
YOGYAKARTA
DENGAN METODE FAILURE MODE EFFECT ANALYSIS

Oleh :

TIM PENINGKATAN MUTU DAN KESELAMATAN PASIEN

RS PKU MUHAMMADIYAH YOGYAKARTA

2015
 BAB I
PENDAHULUAN

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e"+e Failure Mode Effect Analysis (FMEA)

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 BAB II
 FAILURE MODE EFFECT ANAL!I! (FMEA)

A DEFINISI
 Failure Mode Effect Analysis (FMEA) !+!l!h ',!", !l!" ,", ,%",$ 
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B LANGKAH<LANGKAH FMEA
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2. L!%&$!h 2 : Me%-,',% flo#$c%art  el!-!%!%
9 L!%&$!h 9 : I+e%"**$!'* ee$ $e&!&!l!% (!*l,#e +e)
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'$#*%& ( Ris& 'riority Nu"er )
5. L!%&$!h 5 : Mel!$,$!% Root Cause Analysis (RCA) +!% el!$,$!%
I+e%"**$!'* !'!l!h +e%&!% fis%one
= L!%&$!h = : De'!*% ,l!%&
6 L!%&$!h 6 : U*3/! +e'!*% ,l!%&
> L!%&$!h > : E;!l,!'*

C LANGKAH 1 : MENCARI PROSES YANG BERESIKO TINGGI DAN

MEMBENTUK TIM
1 P#'e' Be#*'*$ Y!%& D**l*h U%",$ D*!%!l*'*'
PELAYANAN LABORATORIUM
2 Al!'!% Me*l*h T*$ 
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"!h,% 2015'e/!%-!$*%'*+e% 'eh*%&&! #e#!"! "e#!+* 1<2 *%'*+e% e# 
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 e%*%&$!"!% ,l!h +!#* "!h,% 2019 '+ 201
c. KTD +!% KNC -!%& 'el!! *%* ',+!h "e#!+* !$*/!" $e'!l!h!%
 el!-!%!% l!/#!"#*, !%"!#! l!*% : $e'!l!h!% *+e%"**$!'* !'*e%.
$e'!l!h!% '!l*%&. '!l*%& -!%& "*+!$ ee%,h* '-!#!". $e'!l!h!%
+!% $,#!%& !+e$,!"%-! #'e' ee#*$'!!%. &!%&&,!% !l!" +!% S*'"e
I%#!'* l!/#!"#*, ( Laoratory Infor"ation !yste"LIS).
$e'!l!h!% el!#!%

9 Me%e"!$!% T* FMEA

Ke",! : +# S!*,l!"* A/+*ll!h. MMR  
Se$e#"!#*' : N# A#-!%* Rh!h. SKe. N'
A%&&"! : +# S,l*'"*!#* Re"%8!"*. SOG
+# S,#-!%". SPK 
+# Kh!*#*%! H!'h*!h
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S,+*/- N,# P#!'e"-. A M+ L!/
De8* ,l!%+!#*. AMK 
M,h!!+ H*+!-!". SKe. N'
E"*$ D-!h S,l*'"-8!"*. AMK 
S#* H!#"!"*. SKe. N'
D LANGKAH 2 : MENYUSUN FLO*$C+ART  PELAYANAN
E LANGKAH 9 : IDENTIFIKASI EFEK KEGAGALAN (FAILURE MODE )
F!'eT!h!  Failure Mode 'otential Effect 'otential Cause
Pe%+!"!#!% S,#!" e#*%"!!% "*+!$ < Ke'!l!h!% '!l*%& +!% < P el!-!%!% e%-*!!% RM l!!
+**'* le%&$! ee#*$'!!% < B!#3+e l!/el h!/*'
< S'*!l*'!'* e%"*%&%-! e%&*'*!% -!%& le%&$!
 /el, +*l!$,$!% $e!+! +$"e# 

Ke'!l!h!% e%eel!% < L!#!% h!'*l "*+!$ 'e',!* < N!! *#*'!!
l!/el *+e%"*"!' !'*e% $%+*'* $l*%*' !'*e% < P #'e' *+e%"**$!'* ,l!%& +* ,%*" e%&*#* "*+!$  
< Ke'!l!h !% e%e&!$!% + *!&%'*' +*l!$,$!%

S!l*%& Ke'!l!h!% *+e%"**$!'* < Ke'!l!h!% ee#*$'!!% +!% < N!! *#*'!!
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"*+!$ +*l!$,$!%

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'-!#!" < H!'*l "*+!$ !$,#!" < S!l!h !',$ ;!3,"!*%e#  

Pe%e#*!!% S!el "!%!'!l!h < Ke'!l!h!% ee#*$'!!% +!% < B!#3+e h!/*'"*+!$ "e#'e+*!
'!el *+e%"*"!' el!#!% h!'*l < P#'e' *+e%"**$!'* "*+!$ +*l!$,$!%
 F!'eT!h!  Failure Mode 'otential Effect 'otential Cause
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'-!#!" : h!/*'ED#,'!$ < Ke"*+!$,!'!% !'*e% < Pe#e%3!%!!% $,#!%& "e)!"
< Pe%-*!%!%   "*+!$  'e',!* $%+*'* -&
+*#e$e%+!'*$!%

Ke&!&!l!% pre$treat"ent  < Pe%&,l!%&!% #'e' < Pe%&,!'!!%   "e$%*$   #e!#!'* $,#!%&

 sa"ple #e!#!'* '!le /!*$$e"e%'* '$*ll

Se""*%& !l!" l!! : < Pe%,%+!!% el!-!%!% < Bel, !h! '*'"e !," $!l*/#!'* 'eh*%&&!
e%,%&&, !l!" $!l*/#!'* < Ke"*+!$,!'!% !'*e% /el, +!!" e%&!%"*'*!'*
,l!%& 'e/el, #'e'

S,/e# +!-! l*'"#*$ "*+!$ < Pe%,%+!!% el!-!%!% < S ,l!* l*'"#*$ PLN "*+!$ '"!/*l
e!+!* : !"*. UPS < Ke"*+!$,!'!% !'*e% < Bel, !+! e/!&*!%   $e8e%!%&!%  el!'
#,'!$. +ll !*%"e%!%3e UPS !%"!#! EDP +!% Ele$"#e+*$
 F!'eT!h!  Failure Mode 'otential Effect 'otential Cause
Pe!%"!,!% M,", I%"e#%!l < H!'*l -!%& +*$el,!#$!% "*+!$ < B!h!% $%"#l "*+!$ "e#'e+*!#,'!$ "e#l!/!"
"*+!$ +*l!$,$!% ;!l*+ +!"!%&
< Te%!&! L!/#!"#*, Me+*$ (TLM) "*+!$ 
e%!l!%$!% 'e',!* SPO

K#e$'* Ke'!l!h!% *+e%"**$!'* < Ke'!l!h!% el!#!% h!'*l < T*+!$ e%e#!$!% SPO *+e%"**$!'*
H!'*l '!!" entry data

K%e$'* !%"!#! !l!" < Ke'!l!h!% el!#!% h!'*l < G#,%+ l*'"#*$ "*+!$  e#%!h "e#e%,h* ' e',!*
+e%&!% S*'"e LIS e### '"!%+!#
< K!/el LAN +!% K!/el !#,' l*'"#*$ +*!+*$!% '!",
ee%&!#,h* l!l, l*%"!' +!"! ele$"#%*$ 
< Se'**$!'* $!/el 'e#*!l le/*h l!/!"
+*/!%+*%&$!% +e%&!%3," LAN

H!'*l $#*"*' "*+!$ < Me%&!%3! $e'el!!"!% !'*e% < Pe",&!' /el,( )!h!( )e%"*%&%-! %*l!* $#*"*'
+*l!#$!%

!l*+!'*h!'*l H*'"#* "*+!$ +*!$"*$!% < T*+!$ +!!" e%+e"e$'* < P#'e' ;!l*+!'* /el, "e#'"!%+!#*'!'*/el, !+!
$e3e%+e#,%&!% h!'*l l!/ +!#* SPO $h,','
8!$", $e 8!$",
 F!'eT!h!  Failure Mode 'otential Effect 'otential Cause
T*+!$ !+! ;e#**$!'* < Ke"*+!$'e',!*!% -!%& !$!% < P#'e' ;!l*+!'* /el, "e#'"!%+!#*'!'*
$e'e',!*!% !%"!#! ',#!" e%&h!/!" #'e' /e#*$,"%-!
 e#*%"!!% +!% h!'*l l!/

D*'"#*/,'* $e G!%&&,!% LAN !+! < K,%*$!'* ;*! "ele%  le/*h I%"e#e#e%'*!%"!#! $!/el l*'"#*$ +!% $!/el +!"!LAN
 e%&*#* +*'"#*/,'* h!'*l ;*! LIS /e#*'*$
< Pe%,%+!!% el!-!%!%
 /e#*$,"%-!

S!l!h !l!!" e%&*#*!% : < Ke'!l!h!% el!-!%!% /e#*$,"%-! P#'e' *+e%"**$!'* "*+!$ +*l!$,$!% 'e',!* SPO
 *%+!h $!!#. %!! *#* < Pe%,%+!!% el!-!%!%
+ll /e#*$,"%-!

H!'*l l!/ #!"#*, !'*e% < T*+!$ "e#e$! +* RM !$", ",%& &, el!-!%!% l!/ l!!. $ h,','%-!
 ,l!%& < Me%-,l*"$!% el!-!%!% $%"#l e%&!%"!#!% #*%" ," h!'*l
e%,,$"e#"*%&&!l +* !'*e%
#,!%&!%
 F LANGKAH  : MENETAPKAN TINGKAT KEPARAHAN DARI EFEK KEGAGALAN DENGAN SKORING (  RI!, 
 'RIORIT NUM-ER)
 NO  FAILURE MODE  OCC SE DET RPN PRIORITAS
1 S,#!" e#*%"!!% "*+!$ +**'* le%&$! A 5 2 A0 =
2 Ke'!l!h!% e%eel!% l!/el *+e%"*"!' !'*e% !+! ',#!" e#*%"!!% 2 > > 12> 2
9 Ke'!l!h!% *+e%"**$!'* !'*e% 'e/el, '!l*%& 2 6 9 :2 A
 S!l*%& ,l!%& $#% '!el "*+!$ ee%,h* '-!#!" 9 9 : 9= 12
5 S!el "!%!'!l!h *+e%"*"!' : > 1 92 1:
= Al!" #,'!$  2 = 2 2: 15
6 Re!&e% "*+!$ ee%,h* '-!#!" : h!/*'ED#,'!$  9 6 5 105 5
> Ke&!&!l!% pre treat"ent sa"ple #e!#!'* '!le 2 5 2 20 1>
 Se""*%& !l!" l!! : e%,%&&, !l!" $!l*/#!'* ,l!%& '/l #'e' 5 6 1 95 19
10 S,/e# +!-! l*'"#*$ "*+!$ e!+!* : !"*. UPS #,'!$. +ll = : 5 120 9
11 Pe!%"!,!% M,", I%"e#%!l (PMI) "*+!$ +*l!$,$!% 9 6 1 21 16
12 Ke'!l!h!% *+e%"**$!'* '!!" entry data 2 6 > 112 :
19 K%e$'* !%"!#! !l!" +e%&!% S*'"e LIS e###  6 2 : 5= 6
1 Pee#*$'!!% +!% h!'*l $#*"*' "*+!$ "e#l!/!" +*l!#$!% = A 9 1=2 1
15 H*'"#* "*+!$ +*!$"*$!% ,%",$ ;!l*+!'* 2 = 1 12 1A
1= T*+!$ !+! ;e#**$!'* $e'e',!*!% !%"!#! ',#!" e#*%"!!% +!% h!'*l l!/ > 5 1 0 11
16 G!%&&,!% LAN !+! +*'"#*/,'* h!'*l ;*! LIS 2 2 = 2 1=
1> S!l!h !l!!" e%&*#*!% : *%+!h $!!#. %!! *#* +ll  6 2 5= >
1 H!'*l l!/ !'*e% ,l!%& e%,,$"e#"*%&&!l +* #,!%&!% 6 9 2 2 10
G. LANGKAH 5 : IDENTIFIKASI AKAR PENYEBAB MASALAH ( FI!+$-ONE MET+ODE )
1 HASIL KRITIS TIDAKTERLAMBAT DILAPORKAN

PROCESS Bel, !+! FASILITAS

 Auto$caliration
+$,e%"!'* e%&h!/!" h!'*l
S!el "*+!$ ee%,h* S,l- l*'"#*$ 
 el!#!%
'-!#!" 'eh*%&&! e#l, h!'*l %*l!* "*+!$ e!+!*
'!l*%& ,l!%& $#*"*' +!l!
 /,$, Al!" #,'!$  PEMERIKSAAN 
"e#'e%+*#* e%+!+!$   HASIL KRITIS
TIDAKTERLAMBAT
T*+!$ !h! *$! DILAPORKAN
Ke',l*"!% L!/#!"#*
h!#,' !$"* DP?P ',l*" '!l*%& , #,,$!%
el!#$!% +*h,/,%&* T*+!$ !+!
$!#e%! $e l,!#  
 e%!%&&,%&<!8!/
$%+*'* $,#!%&
h!'*l ee#*$'!!%
Pe#!8!"+$"e#  *'*$. #e'%'*  
$#*"*'
 !&! "e#l!/!"  e%-!$*".
PASIEN  '*$l&*'
l!# $e DP?P Bel, !+! %e;
FAKTOR 
FAKTOR  ORGANISASI

PETUGAS LINGKUNGAN
KER?A MANA?EMEN
2 KESALAHAN PENEMPELAN LABEL IDENTITAS PASIEN PADA SURAT PERMINTAAN

PROSES FASILITAS

Ce$ +!% #*3e$  T*+!$ !+! Ce"!$!% l!/el

!%"!# e",&!'  #*%"e# l!/el (/!#3+e) "e#/!"!'
 /el, /e#!l!%  /!#3+e +*
,%*" e%"*%&

KESALAHAN
LABEL
IDENTITAS
PASIEN
T*+!$ !",h H!/!"!% S,e#;*'* +* l,!# 
"e#h!+! SPO $,%*$!'*  ! $e#! $,#!%&
"*!l Bel, !+! !,+*"
L!+ !'*e% "*%&$!" $e!",h!%
T,l*'!% "*+!$ 
 "*%&&*
A#e! $e#! $e"e!"!% *+e%"**$!'*
 el!' "*+!$ #!*

FAKTOR  Ke"e!"!% *+e%"**$!'*

PETUGAS PASIEN FAKTOR  
LINGKUNGAN ORGANISASI  /el, e/,+!-!
KER?A MANA?EMEN
 9 SUMBER DAYA LISTRIK TIDAK MEMADAI

PROSES FASILITAS

Peel*h!#!!% Se'**$!'* +!%

Peel*h!#!!% *%'"!l!'* UPS !"*"*+!$ /e#,%&'*.
',/e# l*'"#*$ $e/,",h!% S,/e#  
l*'"#*$ /el, !$'*!l 3!+!%&!% (UPS) l*'"#*$ ,"!!  "*+!$ 'e&e#! +*&!%"*
 /el, +*l!$,$!% 3!+!%&!% /el,
#,"*% "e#*+e%"**$!'*
SUMBER LISTRIK 

TIDAK MEMADAI

O;e#he!"*%& +* T*+!$ !+!

Bel, !+! !#e! &e%'e" $,%*$!'* ee$"* 
 e",&!' -%& +e%&!% ,%*" Bel, !+! e/!&*!% ",&!'
+*",%,$   eel*h!#!!%$e"*$!
O;e#he!"*%& +*  el!' *h!$ -!%& el!$,$!%
eel*h!#! UPS !+! e%!/!h!%
 eel*h!#!!% UPS
!#e! l!/#!"#*, !l!" /,",h l*'"#*$ 

FAKTOR LINGKUNGAN FAKTOR  

PETUGAS
KER?A ORGANISASI
MANA?EMEN
H LANGKAH = : DESAINRANCANGAN ULANG PROSES
 NO FM PRIORITAS
1 Pee#*$'!!% +!% h!'*l $#*"*'
"*+!$ "e#l!/!" +*l!#$!%
2 Ke'!l!h!% e%eel!% l!/el
*+e%"*"!' !'*e% !+! ',#!"
 e#*%"!!%
RANCANGAN ULANGPERBAIKAN TARGET AKTU PIC
1 Me%*%&$!"$!% $e+*'*l*%!% e%&*'*!% /,$, 15  Ne/e# 2015 < S; L!/#!"#*,
$h,',' l!#!% h!'*l $#*"*' < K#'h*"
2 E+,$!'*   )e",&!' l!/#!"#*, (TLM) 25 O$"/e# 2015 < K!I%'
 e%"*%&%-! 'e&e#! el!#$!% h!'*l $#*"*' L!/#!"#*,
(e#"e,!%  e/,!"!% '"e#) < K!I%' IGD
< M!%!e# ?!%&Me+*$ 
9 M%*"#*%& +!% e;!l,!'* $e!",h!% "e#h!+! 25 O$"/e# 2015 @ S; L!/#!"#*,
SPO el!#!% h!'*l $#*"*' 15 Ne/e# 2015
 S,#!" e/e#*"!h,!% #e'* +!#* D*#e$",# 26 O$" /e# 2015 S; L!/ #!"#*, 
$e!+! l!/#!"#*, #,,$!% l,!# /e#$!*"!%
+e%&!% '"!%+!# 8!$", ee#*$'!!% $#*"*'
5 Me/,!" SPO #,,$!% ee#*$'!!% $#*"*' $e 26 O$"/e# 2015 < S; L!/#!"#*,
l!/#!"#*, l,!# < M!% ?!%& Me+
1 Pe%!/!h!% ,l!h #*%" ," /!#3+e e#  15 Ne/e# 2015 < M!% RM
!'*e% (20 l!/el /!#3+e 8!$", !',$ < EDP
#!%!. 10 l!/l /!#3+e !',$ #!8!" !l!%) < Pe%&!+!!%
2 M%*"#*%& +!% e;!l,!'* $e!",h!% SPO 15 Ne/e# 2015 T* KPRS
*+e%"**$!'*
9 E;!l,!'* ,#!*!% ",&!' $#+*%!"# 'h*". 15 Ne/e# 2015 M!% SDI
!',$$!% ',e#;*'* #'e' el!-!%!%
 Pe%!"!!% ,l!%&e#!*$!% !#e! $e#! ,%*" 15 Ne/e# 2015 < S; Se,! ,%*"
 )el!-!%!% +!% K!!%-e /,+!-! 5R $e#!
(R*%&$!'.R!*.Re'*$.R!8!". R!*%) < T* PPI
 NO FM PRIORITAS RANCANGAN ULANGPERBAIKAN TARGET AKTU PIC
9 S,/e# +!-! l*'"#*$ "*+ !$ 1 Me% -,',%  ee"!!% , "*l*'!'* l *'"#*$ + !% 15 Ne/e# 2015 M!% ?!% & N %Me+
e!+!* $e/,",h!%
2 Me%-,',% $e/,",h!% 3!", +!-! 3!+!%&!% 15 Ne/e# 2015 M!%?!%& N% Me+
9 Me%e"!$!% Se'**$!'* +!% $e/,",h!% UPS 15 Ne/e# 2015 < M!%?!%& N%
"*! !l!" +!% ,%*" e%"*%& Me+
< S; Ele$"#e+*$ 
 Me%e"!$!% ",&!' +!% $e8e%!%&!% 15 Ne/e# 2015 < Se$#e"!#*!" D*#e$",#  
 eel*h!#!!% UPS. el!l,* %"! +*%!': < S; EDP
! UPS ele$!" !+! !l!" e+*$  < S; Ele$"#e+*$ 
ele$"#e+*$ 
 / UPS ele$!" !+! $,"e#  EDP
5 Me%&,#!%&* !$"# #*'*$ o.er%eatin/  15 Ne/e# 2015
#,!%&!% l!/#!"#*,:
! Me%,", $!3! /!&*!% /!#!" ('ee#"* 15 Ne/e# 2015 M!%?!%& N% Me+
#,!%& #el!'*BP?S)
 / Peel*h!#!!% AC /e#$!l! 15 Ne/e# 2015 S; Peel*h!#!!%
= Me%&,#!%&* !$"# #*'*$ o.er%eatin/   !#e! 15 Ne/e# 2015 S; Peel*h!#!!%
&e%'e"
I LANGKAH 6 : U?ICOBA DESAIN ULANG
G!/!# D*!&#! Se"el!h De'!*% Ul!%&
! D*!&#! Al,# Pe#!l!"!%

Me%*l!* Kel!-!$!%$e/,",h!% !l!" l!/#!"#*,

Pe(/el*!%)e%&!+!!% Peel*h!#!!%   Pe#/!*$!% K!l*/#!'*

Pe%,%,$!% "* Ce$ !+8!l L!)#!% Ce$ !'!

 )e(/el*!% )e(el*h!#!!% $e#,'!$!%  /e#l!$, $!l*/#!'*

Me%e"!)$!% Ke#!'!(! ,%*" Ke#!'!(! ,%*" 9 /,l!% 'e/el,

')e'**$!'* ele$"#e+*$    ele$"#(e+*$   /e#!$h*#.
e%&!,$!%
1 Se'**$!'* !l!" Pe#/!*$!% leh  e#h%!%
2 Ke/,",h!% +!-! ele$"#e+*$ $!l*/#!'* $e
l*'"#*$. !#,'. ',l*e#   BPFK S,#!/!-!
 /roundin/ 

E;!l,!'* +!%
Me%,%&&,
Pe%,%,$$!% #+,$    ,*3/!
$%*#!'* !+8!l
+!% ',l*e# 
$!l*/#!'*

P#'e' e/el*!%
P#'e' $!l*/#!'*

'e#"**$!"
$!l*/#!'*
 / D*!&#! Al,# Pel!-!%!% L!/#!"#*, *

R!8!" ?!l!%

PASIEN

PENDAFTARAN
(TPPR?)

PERIKSA DOKTER 

IDENTIFIKASI

SURAT PERMINTAAN
PEMERIKSAAN
IDENTIFIKASI

ENTRY DATA
PELAYANAN LABORATORIUM
IDENTIFIKASI

SAMPLING DAN
PEMBERIAN LABEL PASIEN
PADA TABUNG SPESIMEN 1 IDENTIFIKASI
2 PENILAIAN
KUALITAS
PREPARASI SPESIMEN

PROSES ANALISIS

KOREKSI HASIL
IDENTIFIKASI

ALIDASI DAN INTERPRETASI

 ALIDASI DAN INTERPRETASI

PEMERIKSAAN  HASIL KRITIS PEMERIKSAAN  HASIL TIDAK 

LAPOR DOKTER PATOLOGI

HUBUNGI IGDPOLIKLINIK  CETAK HASIL

IDENTIFIKASI

HASIL DISERAHKAN PASIEN

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ASESMEN MEDIS

IDENTIFIKASI

SURAT PERMINTAAN
PEMERIKSAAN
IDENTIFIKASI

SAMPLING DAN
PEMBERIAN LABEL PASIEN
PADA TABUNG SPESIMEN

IDENTIFIKASI

ENTRY DATA
PELAYANAN LABORATORIUM
1 IDENTIFIKASI
2 PENILAIAN
KUALITAS
PREPARASI
SPESIMEN

PROSES ANALISIS

KOREKSI HASIL
IDENTIFIKASI

ALIDASI DAN INTERPRETASI

PEMERIKSAAN  HASIL KRITIS PEMERIKSAAN  HASIL TIDAK 

LAPOR DOKTER PATOLOGI

KLINIK 

LAPOR PERAAT RUANG CETAK HASIL

IDENTIFIKASI

HASIL DISERAHKAN
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