10.Langkah Ke 7-Cegah Cedera Melalui Implementasi Keselamatan Pasien (Dr.arjaty)

LANGKAH 7

Dr Dr ArjatyArjaty W W DaudDaud MARSMARS

Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 22

1.1. LATAR BELAKANG PERLUNYA REDESAIN LATAR BELAKANG PERLUNYA REDESAIN PROSES DI PELAYANAN KESEHATANPROSES DI PELAYANAN KESEHATAN

2.2. STRATEGI REDUKSI RISIKOSTRATEGI REDUKSI RISIKO3.3. IDENTIFIKASI PROSES YG RISIKO TINGGI IDENTIFIKASI PROSES YG RISIKO TINGGI 4.4. REDISAIN PROSES :REDISAIN PROSES :

-- FMEAFMEA-- AMKDAMKD®® / HFMEA/ HFMEA


Historical PerspectiveHistorical Perspective

Until recently, error prevention has not Until recently, error prevention has not been a primary focus of medicine been a primary focus of medicine

System/process defects are identified by System/process defects are identified by adverse events or dealt with silently by adverse events or dealt with silently by health care personnelhealth care personnel

Most health care delivery systems are not Most health care delivery systems are not designed to prevent and / or compensate designed to prevent and / or compensate for errorsfor errors

Hingga saat ini, pencegahan kesalahan Hingga saat ini, pencegahan kesalahan medis belum menjadi fokus utama bidang medis belum menjadi fokus utama bidang kedokterankedokteran

Sebagian besar sistem pelayanan Sebagian besar sistem pelayanan kesehatan tidak didesain untuk mencegah kesehatan tidak didesain untuk mencegah atau mencegah / mengatasi atau mencegah / mengatasi ““errorerror””


Identify and prioritize high risk processesIdentify and prioritize high risk processesAnnually select at least one high risk Annually select at least one high risk processprocessIdentify potential Identify potential ““failure modesfailure modes””For each For each ““failure modefailure mode””, identify possible , identify possible effectseffectsFor the most critical effects, conduct a root For the most critical effects, conduct a root cause analysiscause analysis

JCAHO Standard LD 5.2JCAHO Standard LD 5.2(efective July 2001)(efective July 2001)

Identifikasi dan proritaskan Identifikasi dan proritaskan PROSES PROSES YANG BERISIKO TINGGIYANG BERISIKO TINGGIIdentifikasi Identifikasi POTENSI POTENSI ‘‘ MODUS MODUS KEGAGALANKEGAGALAN’’Setiap modus kegagalan, Setiap modus kegagalan, IDENTIFIKASI IDENTIFIKASI ‘‘DAMPAKDAMPAK’’ YANG MUNGKIN TERJADIYANG MUNGKIN TERJADIUntuk setiap dampak yang kritis, Untuk setiap dampak yang kritis, LAKUKAN LAKUKAN ‘‘ANALISIS AKAR MASALAHANALISIS AKAR MASALAH’’. .


Redesign the process to minimize the risk of that Redesign the process to minimize the risk of that failure mode or to protect patients from its failure mode or to protect patients from its effectseffectsTest and implement the redesigned processTest and implement the redesigned processIdentify and implement measures of Identify and implement measures of effectivenesseffectivenessImplement a strategy for maintaining the Implement a strategy for maintaining the effectiveness of the redesigned process over effectiveness of the redesigned process over timeatau proses redisain.timeatau proses redisain.

JCAHO Standard LD 5.2JCAHO Standard LD 5.2(efective July 2001)(efective July 2001)

REDISAIN PROSESREDISAIN PROSES untuk untuk meminimalisasi risiko modus kegagalan meminimalisasi risiko modus kegagalan atau mencegah dampaknya pada pasienatau mencegah dampaknya pada pasienUJI COBA DAN IMPLEMENTASI UJI COBA DAN IMPLEMENTASI REDISAIN PROSESREDISAIN PROSESIDENTIFIKASI DAN NILAI EFEKTIVITAS IDENTIFIKASI DAN NILAI EFEKTIVITAS IMPLEMENTASI IMPLEMENTASI IMPLEMENTASIKAN STRATEGIIMPLEMENTASIKAN STRATEGI untuk untuk efektivitas maintananceefektivitas maintanance


Advanced Patient safety in US since 1999, NPCS, August 2004, www,patientsafety.gov


RISK REDUCTION STRATEGIES DIFFICULTY & RISK REDUCTION STRATEGIES DIFFICULTY & LONG TERM EFFECTIVENESSLONG TERM EFFECTIVENESS

Types of actions Degree of Long term Types of actions Degree of Long term difficulty difficulty effectivenesseffectiveness

Easy LEasy Lowow1.1. PunitivePunitive2.2. Retraining / counselingRetraining / counseling

3.3. Process redesignProcess redesign4.4. ““Paper Paper vsvs practicepractice””5.5. Technical system enhanceTechnical system enhance6.6. Culture changeCulture change

Difficult Difficult HighHigh


Definition of a ProcessDefinition of a Process

A goalA goal--directed interrelated series of directed interrelated series of events, activities, actions, mechanisms, events, activities, actions, mechanisms, or steps or steps that transform inputs into that transform inputs into outputs outputs

(CAMH Glossary)(CAMH Glossary)

INPUT OUTPUTPROSES


STRATEGI REDUKSI RISIKOSTRATEGI REDUKSI RISIKO

IdentifikasiIdentifikasi risikorisiko dgndgn bertanyabertanya 3 3 pertanyaanpertanyaandasardasar : :

1. 1. ApaApa prosesnyaprosesnya ??2. 2. DimanaDimana ““risk pointsrisk points”” / / ““causecause””??3. 3. ApaApa ygyg dapatdapat ““dimitigatedimitigate”” padapada

dampakdampak ““risk pointsrisk points”” ??


STRATEGI REDUKSI RISIKOSTRATEGI REDUKSI RISIKO

RISKPOINTS /

COMMON CAUSES

RENCANA REDUKSI RISIKO

Design Proses u/ Meminimalkan

risikokegagalan

Design Proses u/Mengurangi

DampakKegagalan terjadi

pada pasien

Design Proses u/ Meminimalkan

risikoKegagalan terjadi

Pada pasien


MEMILIH PROSESMEMILIH PROSES

High Risk processes High Risk processes Identified in the literature Identified in the literature Identified by JCAHOIdentified by JCAHOIdentified through safety alertsIdentified through safety alerts

New or redefined processNew or redefined processStaff recommendationsStaff recommendations


IDENTIFYING RISK PRONE SYSTEMIDENTIFYING RISK PRONE SYSTEM

Variable inputVariable inputComplex systemsComplex systemsNon standardized systems Non standardized systems Tightly coupled systemsTightly coupled systemsSystems with tight time constraintsSystems with tight time constraintsSystems with hierarchicalSystems with hierarchical


REDISAIN PROSESREDISAIN PROSES

Variable inputVariable inputComplexComplexNonstandarizedNonstandarizedTightly CoupledTightly CoupledDependent on human Dependent on human interventioninterventionTime constraintsTime constraintsHierarchical cultureHierarchical culture

Decreasing variabilityDecreasing variabilitySimplifySimplifyStandardizing Standardizing Loosen coupling of process Loosen coupling of process Use technologyUse technologyOptimiseOptimise RedundancyRedundancyBuilt in fail safe mechanismBuilt in fail safe mechanismDocumentationDocumentationEstablishing a culture of Establishing a culture of teamworkteamwork

FMEA


Variable input

PasienPenyakit beratPenyakit penyertaPernah mendapatkan pengobatanUsia

Pemberi PelayananTingkat keterampilanCara pendekatan

Proses Pelayanan harus dapat mengakomodasivariabilitas yang tdk dapat dihindarkan dan tidak dapatdikontrol ini.


Complexitas

Pelayanan rumah sakit sangat kompleksMemerlukan beragam langkah yang sangatmungkin berhadapan dengan kegagalanSemakin banyak langkah semakin besarkemungkinan gagalDonald Berwick : 1 langkah -- error 1 %

25 langkah -- error 22%100 langkah -- error 63%


Lack of Standardization

Standard Standard -- ---- prosesproses tidaktidak dapatdapat berjalanberjalansesuaisesuai dengandengan harapanharapan

IndividuIndividu yang yang menjalankanmenjalankan prosesproses harusharusmelaksanakanmelaksanakan langkahlangkah langkahlangkah yang yang telahtelahditetapkanditetapkan secarasecara konsistenkonsistenVariabilitasVariabilitas individual individual sangatsangat tinggitinggi --perluperlu standard standard mismis : SPO, Parameter, : SPO, Parameter, ProtokolProtokol, , Clinical Pathways Clinical Pathways dapatdapat membatasimembatasi pengaruhpengaruhdaridari variabelvariabel yang yang adaada. .


Heavily dependent on human Intervention

Ketergantungan yang tinggi akan intervensiseseorang dalam proses dapat menimbulkanvariasi penyimpangan.Tidak semua improvisasi bersifat buruk, dikenal“ creating safety at the sharp end “Pelayanan kesehatan sangat tergantung padaintervensi manusiaPetugas harus mampu mengendalikan situasiyang tidak terduga demi keselamatan pasienSangat tergantung pada pendidikan dan pelatihanyang memadai sesuai dengan tugas & fungsinya


Tightly Coupled

Perpindahan langkah dari suatu proses sering sangatketat, kadang baru disadari terjadi penyimpanganpada langkah yang telah lanjut.

Keterlambatan dalam suatu langkah akanmengakibatkan gangguan pada seluruh proses

Kekeliruan dalam suatu langkah akan mengakibatkanpenyimpangan pada langkah berikut ( cascade of faillure )

Kesalahan biasanya terjadi pada saat perpindahanlangkah atau adanya langkah yang terabaikan


Hierarchical cultureSuatu proses akan menghadapi risiko kegagalan lebihtinggi dalam unit kerja dengan budaya “hirarki”dibandingkan dengan unit kerja yang budayanyaberorientasi pada “team”.

Staf enggan berkomunikasi & berkolaborasi satu denganyang lain

Perawat enggan bertanya kepada dokter atau petugasfarmasi tentang medikasi, dosis, serta element perawatanlainnya

Budaya hirarki sering tercipta misalnya dalam menentukanpenggunaan obat, verifikasi lokasi pembedahan oleh timbedah.

Tata cara berkomunikasi antar staf dalam prosespelayanan kesehatan sangat menentukan hasilnya.


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 : ~ OmmissionSuasana hierarki lebih datar

~ Kesalahan PengambilanKeputusan


What is FMEA ?What is FMEA ?

AdalahAdalah metodemetode perbaikanperbaikan kinerjakinerja dgndgnmengidentifikasimengidentifikasi dandan mencegahmencegah potensipotensi kegagalankegagalansebelumsebelum terjaditerjadi. Hal . Hal tersebuttersebut didesaindidesain untukuntukmeningkatkanmeningkatkan keselamatankeselamatan pasienpasien. . AdalahAdalah prosesproses proaktifproaktif, , dimanadimana kesalahankesalahan dptdptdicegahdicegah & & diprediksidiprediksi. . MengantisipasiMengantisipasi kesalahankesalahan akanakan meminimalkanmeminimalkandampakdampak burukburuk


FMEA FMEA ––WhatWhat’’s the point?s the point?

Eliminating or reducing the risk of the failure Eliminating or reducing the risk of the failure modes can result in a modes can result in a

SAFER AND MORE EFFICIENT SYSTEM SAFER AND MORE EFFICIENT SYSTEM from which both you and your patients benefit.from which both you and your patients benefit.

Dengan mengeliminasi atau mereduksi Dengan mengeliminasi atau mereduksi risiko kegagalan akan menghasilkan suaturisiko kegagalan akan menghasilkan suatu

SISTEM YANG AMAN DAN LEBIH EFISIENSISTEM YANG AMAN DAN LEBIH EFISIENBAGI RS DAN PASIENBAGI RS DAN PASIEN..


Failure Mode and Effects AnalysisFailure Mode and Effects Analysis

1. Define failure mode.1. Define failure mode.

2. Identify cause of failure.2. Identify cause of failure.

3. Identify effects of failure3. Identify effects of failure

4. Corrective action.4. Corrective action.

what could go wrong?

why would the failure happen?

what would be the consequences of each failure?


FMEA TerminologyFMEA Terminology

Process FMEAProcess FMEA -- Conduct an FMEA on a Conduct an FMEA on a process that is already in placeprocess that is already in place

Design FMEADesign FMEA –– Conduct an FMEA before Conduct an FMEA before a process is put into placea process is put into place

Implementing an electronic medical records or Implementing an electronic medical records or other automated systemsother automated systemsPurchasing new equipmentPurchasing new equipmentRedesigning Emergency Room, Operating Redesigning Emergency Room, Operating Room, Floor, etc.Room, Floor, etc.


FAILURE MODE AND EFFECTS ANALYSISFAILURE MODE AND EFFECTS ANALYSIS

FAILURE (F)FAILURE (F) : When a system or part of a system : When a system or part of a system performs in a way that is not performs in a way that is not intended or desirableintended or desirable

MODE (M)MODE (M) : The way or manner in which : The way or manner in which something such as a failure can something such as a failure can happen. Failure mode is the happen. Failure mode is the manner in which something can manner in which something can fail.fail.

EFFECTS (E)EFFECTS (E) : The results or consequences of a : The results or consequences of a failure modefailure mode

Analysis (A)Analysis (A) : The detailed examination of the : The detailed examination of the elements or structure of a processelements or structure of a process


Why should my organization Why should my organization conduct an FMEA ?conduct an FMEA ?

Can prevent errors & nearCan prevent errors & near misses misses protecting protecting patients from harm.patients from harm.Can Can increase the effectiveness & efficiency of increase the effectiveness & efficiency of

processprocessTaking a proactive approach to patient safety Taking a proactive approach to patient safety also makes good business sense in a health also makes good business sense in a health care environment that is increasingly facing care environment that is increasingly facing demands from consumers, regulators & payers demands from consumers, regulators & payers to create culture focused on to create culture focused on reducing risk & reducing risk & increasing accountabilityincreasing accountability


FMEA has been around for over 30 yearsFMEA has been around for over 30 yearsRecently gained widespread appeal Recently gained widespread appeal outside of safety areaoutside of safety areaNew to healthcareNew to healthcare

Frequently used reliability & system safety Frequently used reliability & system safety analysis techniquesanalysis techniquesLong industry track recordLong industry track record : Aviation, : Aviation, Nuclear power, Aerospace, Chemical Nuclear power, Aerospace, Chemical process industries, Automoiveprocess industries, Automoive

Where did FMEA come from ?Where did FMEA come from ?


LANGKAH FMEA

1. Select a high risk process & assemble a team2. Diagram the process3. Brainstorm potential failure modes & determine their

effects (P X S X D)4. Prioritize failure modes5. Identify root causes of failure modes (P X S X D)6. REDESIGN THE PROCESS7. Analyze & test the new process8. Implement & monitor the redesigned process


Step OneStep OneSelect 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 TwoStep TwoHave the team meet together to list all the

steps in the processNumber every step in the process and be as Number every step in the process and be as

specific as possiblespecific as possible


Step ThreeStep ThreeHave the team list failure modes and effectHave the team list failure modes and effect

List anything that could go wrong including List anything that could go wrong including minor and rare problemsminor and rare problemsIdentify all possible causes for each failure modeIdentify 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



RATING SYSTEM(Modified by IMRK)

Rating Probabilitas(P)

Severity(S)

Deteksi(D)

1 Remote

Low likelihood

Moderate likelihood

High likelihood

Certain to occur

Minor effect Certain to detect

2 Moderate effect High likelihood

3 Minor injury Moderate likelihood

4 Major injury Low likelihood

5 Catastrophic effect / terminal injury,

death

Almost certain not to detect

Risk Priority Number (RPN) / Criticaly Index (CI) = (P x S) x D


Step fourStep four

Prioritize failure mode

Step fiveStep fiveHave 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


Step SixStep SixREDESIGN PROCESS

Determine which failures to work onCalculate the RISK PRIORITY NUMBER (RPN): (RPN): Likelihood x Severity x DetectionLikelihood x Severity x DetectionIdentify the failure modes with the top 10 RPNsIdentify the failure modes with the top 10 RPNs

TAKE A DEEP BREATHTAKE A DEEP BREATHConduct a literature search to Conduct a literature search to gather relevant gather relevant information from the professional literatureinformation from the professional literature. Do not . Do not reinvent the wheelreinvent the wheelNetwork with colleaguesNetwork with colleaguesRECOMMIT TO OUT OF THE BOX THINKINGRECOMMIT TO OUT OF THE BOX THINKING


Step SevenStep SevenAnalyze and test the new processAnalyze and test the new processUse RPNs to plan improvement effortsUse RPNs to plan improvement efforts

Failure modes with high RPNs are usually the most Failure modes with high RPNs are usually the most important parts of the process to concentrate important parts of the process to concentrate improvement efforts.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 processThen the team should calculate a new criticality index (CI) or RPN.


Step EightStep Eight

Implement & monitor the redesigned process

Design improvements should bring reduction in the CI / RPN. Ex: 30 – 50% reduction ?


What is HFMEA ?What is HFMEA ?Modified by VA NCPSModified 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)


HFMEA Components and Their OriginsHFMEA Components and Their OriginsConceptsConcepts HFMEAHFMEA FMEAFMEA HACCPHACCP RCARCA

Team membershipTeam membership VV VV VV

Diagramming Diagramming processprocess

VV VV VV

Failure mode & Failure mode & causescauses

VV VV

Hazard Scoring Hazard Scoring MatrixMatrix

VV VV

Severity & Probability Severity & Probability DefinitionsDefinitions

VV ## VV

Decision TreeDecision Tree VV VV

Actions & OutcomesActions & Outcomes VV ## VV

Responsible person Responsible person & management & management concurrenceconcurrence

VV ## VV

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 toconsult 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….η team meeting plus 1

Assign team members to follow up individual charged with taking corrective action

η team meeting plus 2 Refine corrective actions based on feedback

η team meeting plus 3 Test the proposed changesη team meeting plus 4 Meet with Top Management to obtain approval for all actionsPostteam meeting The advisor or his/ her designee follow up until all actions are

completed

LANGKAH-LANGKAHANALISIS MODUS KEGAGALAN & DAMPAK (AMKD)®

(HEALTHCARE FAILURE MODE EFFECT AND ANALYSIS) (HFMEA)

By : VA NCPS

1. 1. TetapkanTetapkan TopikTopik AMKD AMKD 2. 2. BentukBentuk TimTim3. 3. GambarkanGambarkan AlurAlur ProsesProses4. 4. BuatBuat Hazard AnalysisHazard Analysis5. 5. TindakanTindakan dandan PengukuranPengukuran OutcomeOutcome


Step 1Step 1

Define the Scope of HFMEA along with a Define the Scope of HFMEA along with a clear definition of the process to be clear definition of the process to be studiedstudied

Step 2Step 2Multidisiplinary team with Subject matter Multidisiplinary team with Subject matter expert(s) plus advisorexpert(s) plus advisor


Step 3Step 3Develop and verify the flow DiagramDevelop and verify the flow Diagram (this is a (this is a process vs chronological diagram)process vs chronological diagram)Consecutively number each processConsecutively number each process step step identified in the process flow diagramidentified in the process flow diagramIf the process is complex If the process is complex identify the area of the identify the area of the process to focus onprocess to focus on (manageable bite)(manageable bite)Identify all sub processes under each block of Identify all sub processes under each block of this flow diagramthis flow diagram. Consecutively letter these sub . Consecutively letter these sub stepsstepsCreate a flow diagram composed of the sub Create a flow diagram composed of the sub processesprocesses


Step 4Step 4

List List Failure modesFailure modesDetermine Determine Severity & ProbabilitySeverity & ProbabilityUse the Use the Decision treeDecision treeList all Failure mode List all Failure mode causescauses


Step 5Step 5Decide to Decide to ““EliminateEliminate”” ControlControl”” or or ““AcceptAccept”” the the failure mode causefailure mode causeDescribe an Describe an action for each failure mode causeaction for each failure mode causethat will eliminate or control it.that will eliminate or control it.Identify Identify outcome measuresoutcome measures that will be used to that will be used to analyze and test the reanalyze and test the re--designed processdesigned processIdentify a single, Identify a single, responsible individualresponsible individual by title to by title to complete the recommended actioncomplete the recommended actionIndicate whether Indicate whether top management has top management has concurredconcurred with the recommended actionswith the recommended actions


FMEAOriginal

HFMEA By : VA NCPS

HFMECA®By IMRK

11 Select a high risk process & assemble a team

Define the HFMEA Topic

Assemble the Team

Graphically describe the Process

Conduct a Hazard AnalysisActions & Outcome Measures

77 Analyze & test the new process REDESIGN THE PROCESS

Select a high risk process & assemble a team

22 Diagram the process Diagram the process

33 Brainstorm potential failure modes & determine their effects (P X S X D)

Brainstorm potential failuremodes(P X S) x K X D, Bands

44 Prioritize failure modes Prioritize failure modes

55 Identify root causes of failure modes(P X S X D)

Identify root causes of failure modes (P X S) x K X D, Bands

66 REDESIGN THE PROCESS CALCULATE TOTAL RPN

88 Implement & monitor the redesigned process

Analyze & test the new process

99 Implement & monitor the redesigned process

FMEAFMEA vsvs HFMEAHFMEA vsvs HFMECAHFMECA®®


RATING SYSTEM HFMECA(Modified by IMRK)

Rating Probabilitas(P)

Severity(S)

Kontrol(K)

Deteksi(D)

1 Remote

Low likelihood

Moderate likelihood

High likelihood

Minor effect

Certain to occur

Certain to detect

2 Moderate effect

Easy

MpderateEasy

Moderate difficult

Difficult

High likelihood

3 Minor injury Moderate likelihood

4 Major injury Low likelihood

5 Catastrophic effect / terminal injury,

death

Almost certain not to detect

Risk Priority Number (RPN) / Criticaly Index (CI) = (P x S) x K x D



LANGKAH 1 : PILIH PROSES YANG BERISIKO TINGGILANGKAH 1 : PILIH PROSES YANG BERISIKO TINGGI

PilihPilih ProsesProses berisikoberisiko tinggitinggi yang yang akanakan dianalisadianalisa. .

JudulJudul ProsesProses ::________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________LANGKAH 2 : BENTUK TIMLANGKAH 2 : BENTUK TIM

KetuaKetua : : ________________________________________________________________________________________________________________________

AnggotaAnggota 1. _______________ 1. _______________ 4. 4. ________________________________________________________________________________

2. _______________ 52. _______________ 5. . ________________________________________ ________________________________________

3. _______________ 63. _______________ 6. . ________________________________________________________________________________

NotulenNotulen?? __________________________________________________________________________________ApakahApakah semuasemua Unit yang Unit yang terkaitterkait dalamdalam ProsesProses sudahsudah terwakiliterwakili ?? YA / TIDAKYA / TIDAKTanggalTanggal dimulaidimulai ____________________ ____________________ TanggalTanggal selesaiselesai ______________________________________


Contoh kasus 1Contoh kasus 1






ANALISIS HAZARD ANALISIS HAZARD ““LEVEL DAMPAKLEVEL DAMPAK””DAMPADAMPA

KKMINOR MINOR

11MODERAT MODERAT

22MAYOR

3KATASTROPIK

4

KegagalanKegagalan yang yang tidaktidakmengganggumengganggu ProsesProsespelayananpelayanan kepadakepadaPasienPasien

Kegagalan dapat Kegagalan dapat mempengaruhi proses mempengaruhi proses dan menimbulkan dan menimbulkan kerugian ringankerugian ringan

Kegagalan menyebabkankerugian berat

Kegagalan menyebabkan kerugian besar

Pasien Pasien Tidak ada cedera,Tidak ada cedera,Tidak ada Tidak ada

perpanjangan perpanjangan hari rawat hari rawat

Cedera ringan Cedera ringan Ada Perpanjangan Ada Perpanjangan hari rawat hari rawat

Cedera luas / beratPerpanjangan hari

rawat lebih lama (+> 1 bln)Berkurangnya fungsi

permanen organ tubuh (sensorik / motorik / psikcologik / intelektual)

Kematian Kehilangan fungsi tubuh

secara permanent (sensorik, motorik, psikologik atau intelektual) mis :Operasi pada bagian atau

pada pasien yang salah, Tertukarnya bayi

PengunjuPengunjungng

Tidak ada cederaTidak ada cederaTidak ada penangananTidak ada penangananTerjadi pada 1Terjadi pada 1--2 org 2 org

pengunjungpengunjung

Cedera ringan Cedera ringan Ada Penanganan Ada Penanganan

ringanringanTerjadi pada 2 Terjadi pada 2 --44

pengunjungpengunjung

Cedera luas / beratPerlu dirawat Terjadi pada 4 -6

orangpengunjung

Kematian Terjadi pada > 6 orang pengunjung

Staf:Staf: Tidak ada cederaTidak ada cederaTidak ada penangananTidak ada penangananTerjadi pada 1Terjadi pada 1--2 staf2 stafTidak ada kerugian Tidak ada kerugian

waktu / keckerjawaktu / keckerja

Cedera ringan Cedera ringan Ada Penanganan / Ada Penanganan /

TindakanTindakanKKehilangan waktu / ehilangan waktu /

kec kerja kec kerja : 2: 2--4 staf4 staf

Cedera luas / beratPerlu dirawat Kehilangan waktu / kecelakaan kerja pada 4-6 staf

KematianPerawatan > 6 staf

Fasilitas Fasilitas KesKes

Kerugian < 1 000,,000 Kerugian < 1 000,,000 atau tanpa menimbulkan atau tanpa menimbulkan dampak terhadap pasiendampak terhadap pasien

Kerugian Kerugian 1,000,000 1,000,000 --10,000,00010,000,000

Kerugian 10,000,000 - 50,000,000

Kerugian > 50,000,000


ANALISIS ANALISIS HAZARDHAZARD ””LEVEL PROBABILITASLEVEL PROBABILITAS””

LEVELLEVEL DESKRIPSIDESKRIPSI CONTOH CONTOH

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

33 KadangKadang--kadangkadang(Occasional)(Occasional)

KemungkinanKemungkinan akanakan munculmuncul((dapatdapat terjaditerjadi bebearapabebearapa kali kali dalamdalam 1 1

sampaisampai 2 2 tahuntahun))

22 JarangJarang (Uncommon)(Uncommon) Kemungkinan akan muncul Kemungkinan akan muncul (dapat terjadi dalam >2 sampai 5 tahun)(dapat terjadi dalam >2 sampai 5 tahun)

11 Hampir Tidak Pernah Hampir Tidak Pernah (Remote)(Remote)

Jarang sekali terjadi (dapat terjadi dalam Jarang sekali terjadi (dapat terjadi dalam > 5 sampai 30 tahun)> 5 sampai 30 tahun)


HAZARD SCORETINGKAT BAHAYATINGKAT BAHAYA

KATASTROPIKKATASTROPIK44

MAYORMAYOR33

MODERAT MODERAT 22

MINORMINOR11

SERINGSERING44

1616 1212 88 44

KADANGKADANG33

1212 99 66 33

JARANGJARANG22

88 66 44 22

HAMPIR TIDAK HAMPIR TIDAK PERNAHPERNAH

11

44 33 22 11


Does this hazard involve a sufficient likelihood of

occurrence and severity to warrant that it be

controlled?(Hazard score of 8 or

higher) Is this a single point weakness in the process? (Criticality – failure

results in a system failure?)CRITICALY

Does an effective control measure already exist for the identified hazard?

CONTROL

Is this hazard so obvious and readily apparent that a control measure is not

warranted? DETECTABILITY

STOP

NO

NO

NO

NO

YES

YES

YES

YES

Proceed to Potential

Causes for this failure

mode

Do not proceed to find potentialcauses for this failure mode

Decision TreeDecision TreeGunakan Decision Tree utk menentukan apakah modus perlu tindakan lanjut

di“Proceed”..


Contoh kasus 2Contoh kasus 2PROSES KEGIATAN PAGI HARI MENUJU TEMPAT KERJA









LEMBAR AMKD ( FORM HFMEA )

AMKD AMKD LangkahLangkah 4 4 -- AnalisisAnalisis Hazard Hazard AMKD AMKD LangkahLangkah 5 5 -- IdentifikasiIdentifikasi TindakanTindakan & Outcome& Outcome

SKORINGSKORING AnalisisAnalisis PohonPohon KeputusanKeputusan

Nilai

Nilai H

azardH

azard

PoinPoin

Tunggal Tunggal

Kelem

ahanK

elemahan

??

Apakah m

udah A

pakah mudah

didteksi ?didteksi ?

TipeTipeTindakanTindakan((KontrolKontrol, , terimaterima, ,

EliminasiEliminasi))

TindakanTindakan / / AlasanAlasanuntukuntuk

mengakhirimengakhiriU

kuranU

kuranO

utcome

Outcom

e

Turn off alarmTurn off alarm majormajor occasoccasionalional

99 NN NN

NN

YY

Missed Missed snooze buttonsnooze button

majormajor OccaOccasionalsional

99 NN YY EliminateEliminate Purchased Purchased new clocknew clock

PurcPurchasehased by d by certcertain ain datedate..........

Mr..Mr.. YesYes

ProbabilitasProbabilitas

ProsesProses

??

Yang Yang B

ertanggungB

ertanggungJaw

abJaw

abMODUSMODUS

KegagalanKegagalan ::EvaluasiEvaluasi awalawal

modus modus kegagalankegagalansebelumsebelum

POTENSIPOTENSIPENYEBABPENYEBAB

Kegaw

atanK

egawatan

AApakah ada pakah ada

kontrol/pengenkontrol/pengen

dalian?dalian?

Manajem

enM

anajemen

TimTim

HFMEA : Healthcare Failure Mode Effect and Analysis


Proses lamayg high risk

AlurProses

DesainProses baru

Potential Cause

FailureMode HS

Efek /Dampak

Decision Tree

KK

DT

K

E

Tindakan

AMKD / HFMEA

HazardScore

KontrolEliminasiTerima

KritisKontrolDeteksi


AMKDP / HFMECA

PrioritasPrioritasrisikorisiko

Total RPN Total RPN PROSES PROSES LAMALAMA

FailureFailure

Mode,Mode,

DampakDampak, ,

PenyebabPenyebab

RedisignRedisignProsesProses

AnalisisAnalisis &&UjiUji ProsesProses BaruBaru

Total RPN Total RPN PROSES PROSES BARU BARU

FailureFailureMode,Mode,DampakDampak, , PenyebabPenyebab

ImplementasiImplementasiPROSES BARUPROSES BARU

Total RPN30-50%?


KESIMPULANKESIMPULANBuilding a safe healthcare systemBuilding a safe healthcare system

DETEKSI

KONTROL

SEVERITY

FREKUENSI

LEARNING

RE

PO

RT

IN

G

ANALISIS

KOMUNIKASI

CU

LT

UR

E

TRAINING

TE

AM

WO

RK

L E A D E R S H I P


Team WorkTeam Work ??

?

Documents

10.Langkah Ke 7-Cegah Cedera Melalui Implementasi Keselamatan Pasien (Dr.arjaty)