LANGKAH 7

1. LATAR BELAKANG PERLUNYA REDESAIN PROSES DI

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

Arjaty/ IMRK 2
 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
oleh events
tenaga medis or dealt with silently by health
care personnel
Sebagian besar sistem pelayanan kesehatan tidak
Most health
didesain untukcare delivery
mencegah atausystems are not
mengkompensasi
designed
suatu to prevent and / or compensate for
kesalahan
errors
Arjaty/ IMRK 3
 Rationale for FMEA in healthcare
Historically
Pencegahan .......insiden belum menjadi fokus
Accident
utama pelayanan
prevention rumah
has not
sakit
been a primary
focus
Adanyaof hospital
persepsimedicine
yang salah tentang
Misguided
kegagalanreliance on faultles
dalam pelayanan performance
oleh profesi
by healthcare professionals
kesehatan
Hospital systems were not designed to
Sistem rumah sakit tidak didesain untuk
prevent or absorb error, they just reactively
mencegah kesalahan, mereka hanya
changed and were not typically proactive reaktif
dan tidak proaktif
Arjaty/ IMRK NCPS 4
 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,
Paling one high-risk process
pilih satu is chosen
masalah annually,
berisiko thetahunnya,
tinggi tiap choice
should be basedpilihin part on information
berdasarkan published
evaluasi periodikperiodically
by the Joint Commission about the most frequent sentinel
events and risks.

Arjaty/ IMRK 5
*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
for identifying
dalam penerapan
risks to patient
program
safetysecara
andreducing
proaktif
medical
mengidentifikasi
/ health care
risikoerrors
yangistujuannya
defined and
bagi
keselamatan pasien implemented
dan mereduksi kesalahan medis

The organization
Organisasi seeksmereduksi
akan berusaha to reduce the riskkejadian
risiko of sentinel events and
berbahaya ataumedical
/ healthmedis
kesalahan care system
denganerror relatedusaha
melakukan occurrences
proaktifbymenggunakan
conducting itsinformasi
own
yangproactive
tersediarisk
dariassessment
kejadian lainactivities and bykesamaan
yang memiliki using available information
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
dicegah effort is undertaken so that
yang merugikan processes, functions & services can be
organisasi
DESIGNED or REDEDIGNED to prevent such occurrences in the
organization.
Arjaty/ IMRK 6
 JCAHO Standard LD 5.2
(efective July 2001)

Identify and dan

Identifikasi prioritize high risk
proritaskan processes
proses yang
Annually
berisiko select
tinggi at least one high risk process
Identify potential
Identifikasi failure
potensi modes
modus kegagalan
For eachmodus
Setiap failurekegagalan,
mode, identify possible
identifikasi dampak
effects
yang mungkin terjadi
For the setiap
Untuk most critical
dampak effects,
yang conduct a root
kritis, lakukan
analisis
cause akar masalah.
analysis

Arjaty/ IMRK 7
 JCAHO Standard LD 5.2
(efective July 2001)

Redesign the process to minimize the risk of that

Redisain 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
Identifikasi of
effectiveness danthenilai efektivitas
redesigned implementasi
process over
timeatau proses redisain.
Implementasikan strategi untuk efektivitas
maintanance

Arjaty/ IMRK 8
 RISK REDUCTION STRATEGIES DIFFICULTY &
LONG TERM EFFECTIVENESS
Types of actions Degree of Long term
difficulty effectiveness

Easy Low
1. Punitive
2. Retraining / counseling
3. Process redesign
4. Paper vs practice
5. Technical system enhance
6. Culture change
Difficult High
Arjaty/ IMRK 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
Pada pasien pada pasien12
 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 Decreasing variability

Simplify
Complex
Standardizing
Nonstandarized Loosen coupling of process
Tightly Coupled Use technology
Dependent on human Optimise Redundancy
intervention Built in fail safe mechanism
Time constraints Documentation
Establishing a culture of
Hierarchical culture teamwork

Arjaty/ IMRK 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?

Eliminating
Denganor reducing
mengeliminasi
the riskatau
of the
mereduksi
failure modes
risiko kegagalancan result
akan in a
menghasilkan suatu
SAFER YANG
SISTEM AND MORE
AMANEFFICIENT
DAN LEBIHSYSTEMEFISIEN
from which BAGI
both you
RS and
DANyour patients benefit.
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.

why would the failure
happen?
3. Identify effects of failure
what would be the
consequences of each
failure?
4. Corrective action.
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 HFMEA HFMECA
Original By : VA NCPS By IMRK
1 Select a high risk process & Define the HFMEA Select a high risk process &
assemble a team Topic assemble a team
2 Diagram the process Assemble the Team Diagram the process

3 Brainstorm potential failure modes & Graphically describe Brainstorm potential failure modes
determine their effects the Process (P X S) x K X De, Bands
(P X S X De)
4 Prioritize failure modes Conduct a Hazard Prioritize failure modes
Analysis
5 Identify root causes of failure modes Actions & Outcome Identify root causes of failure modes
(P X S X De) Measures (P X S) x K X De, Bands

6 REDESIGN THE PROCESS CALCULATE TOTAL RPN

7 Analyze & test the new process REDESIGN THE PROCESS

8 Implement & monitor the redesigned Analyze & test the new process
process
9 Arjaty/ IMRK Implement & monitor the redesigned
39
process
 RATING SYSTEM
(Modified by IMRK)

Rating Probabilitas Severity Kontrol Deteksi

(P) (S) (K) (D)
1 Remote Minor effect Easy Certain to detect

2 Low likelihood Moderate effect Mpderate Easy High likelihood

3 Moderate Minor injury Moderate Moderate

likelihood difficult likelihood

4 High likelihood Major injury Difficult Low likelihood

5 Certain to occur Catastrophic effect / Almost certain

terminal injury, death 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 V V V

Diagramming process V V V

Failure mode & causes V V

Hazard Scoring Matrix V V

Severity & Probability V # V

Definitions
Decision Tree V V

Actions & Outcomes V # V

Responsible person & V # V

management
concurrence
Arjaty/ IMRK 42
HACCP : Hazard Analysis Critical Control Point
 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 Assign team members to follow up individual charged with taking corrective
meeting plus 1 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 HAZARD LEVEL DAMPAK
DAMPAK MINOR MODERAT MAYOR KATASTROPIK
1 2 3 4
Kegagalan yang tidak Kegagalan dapat Kegagalan menyebabkan Kegagalan menyebabkan kerugian
mengganggu Proses mempengaruhi proses kerugian berat besar
pelayanan kepada Pasien dan menimbulkan
kerugian ringan
Pasien Tidak ada cedera, Cedera ringan Cedera luas / berat Kematian
Tidak ada perpanjangan Ada Perpanjangan Perpanjangan hari rawat Kehilangan fungsi tubuh
hari rawat hari rawat lebih lama (+> 1 bln) secara permanent (sensorik,
Berkurangnya fungsi motorik, psikologik atau
permanen organ tubuh intelektual) mis :
(sensorik / motorik / Operasi pada bagian atau
psikcologik / intelektual) pada pasien yang salah,
Tertukarnya bayi

Pengunju Tidak ada cedera Cedera ringan Cedera luas / berat Kematian
ng Tidak ada penanganan Ada Penanganan Perlu dirawat Terjadipada > 6 orang
Terjadi pada 1-2 org ringan Terjadi pada 4 -6 orang pengunjung
pengunjung Terjadi pada 2 -4 pengunjung
pengunjung
Staf: Tidak ada cedera Cedera ringan Cedera luas / berat Kematian
Tidak ada penanganan Ada Penanganan / Perlu dirawat Perawatan > 6 staf
Terjadi pada 1-2 staf Tindakan Kehilangan waktu /
Tidak ada kerugian Kehilangan waktu / kecelakaan kerja pada
waktu / keckerja kec kerja : 2-4 staf 4-6 staf
Fasilitas Kerugian < 1 000,,000 Kerugian Kerugian Kerugian > 50,000,000
Kes atau tanpa menimbulkan 1,000,000 - 10,000,000 - 50,000,000
Arjaty/ IMRK 54
dampak terhadap pasien 10,000,000
 ANALISIS HAZARD LEVEL PROBABILITAS

LEVEL DESKRIPSI CONTOH

4 Sering (Frequent) Hampir sering muncul dalam waktu yang
relative singkat (mungkin terjadi beberapa
kali dalam 1 tahun)

3 Kadang-kadang Kemungkinan akan muncul

(Occasional) (dapat terjadi bebearapa kali dalam 1 sampai
2 tahun)

2 Jarang (Uncommon) Kemungkinan akan muncul

(dapat terjadi dalam >2 sampai 5 tahun)
1 Hampir Tidak Pernah Jarang sekali terjadi (dapat terjadi dalam > 5
(Remote) sampai 30 tahun)

Arjaty/ IMRK 55
 HAZARD SCORE
TINGKAT BAHAYA
KATASTROPIK MAYOR MODERAT MINOR
4 3 2 1
SERING 16 12 8 4
4
KADANG 12 9 6 3
3
JARANG 8 6 4 2
2
HAMPIR TIDAK 4 3 2 1
PERNAH
1

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 NO
warrant that it be controlled?
(Hazard score of 8 or
higher)
Is this a single point weakness in the
NO
YES process? (Criticality failure results
in a system failure?)
CRITICALY
YES
Does an effective control measure already YES
exist for the identified hazard? STOP
CONTROL Do not proceed to
NO find potential
causes for this
Is this hazard so obvious and readily failure mode
apparent that a control measure is not YES
warranted?
DETECTABILITY Proceed to
NO Potential
Arjaty/ IMRK Causes for 57
this failure
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
Arjaty/ IMRK 66
Arjaty/ IMRK 67
 LEMBAR AMKD ( FORM HFMEA )

AMKD Langkah 4 - Analisis Hazard AMKD Langkah 5 - Identifikasi Tindakan & Outcome

MODUS SKORING Analisis Pohon Keputusan

Yang Bertanggung
Ukuran Outcome

Manajemen Tim
Kegagalan : Tindakan /

kontrol/pengen

Apakah mudah
Tipe

Poin Tunggal
Kelemahan ?
Probabilitas

Nilai Hazard
Alasan untuk

Apakah ada
Kegawatan
Evaluasi awal POTENSI

didteksi ?
Tindakan

Jawab
Proses ?
dalian?
modus PENYEBAB mengakhiri
(Kontrol,
kegagalan terima,
sebelum Eliminasi)

Turn off alarm major occasi 9 N N Y

onal

Missed snooze major Occasi 9 N N Y Eliminate Purchased Purc Mr.. Yes

button onal new clock hase
d by
certai
n
date.
....

Arjaty/ IMRK 68

HFMEA : Healthcare Failure Mode Effect and Analysis

 AMKD / HFMEA
Proses lama
yg high risk

Alur
Potential Cause Efek / Decision Tindakan
Proses
Dampak Tree
Failure K
K
Mode HS
K
E
D
T
Desain Hazard
Proses baru Kritis Kontrol
Score Kontrol Eliminasi
Deteksi Terima

Arjaty/ IMRK 69
 AMKDP / HFMECA

Total RPN Analisis &

PROSES LAMA Uji Proses Baru
Total RPN Implementasi
Prioritas Failure Redisign PROSES BARU PROSES BARU
risiko Proses
Mode, Failure
Dampak, Mode,
Dampak,
Penyebab Penyebab

Total RPN
30-50%?

Arjaty/ IMRK 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

L E A D E R S H I P
Arjaty/ IMRK 78
Arjaty/ IMRK 79