10.langkah ke 7-cegah cedera melalui implementasi keselamatan pasien (dr.arjaty)
TRANSCRIPT
LANGKAH 7
Dr Dr ArjatyArjaty W W DaudDaud MARSMARS
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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
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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””
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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’’. .
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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
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Advanced Patient safety in US since 1999, NPCS, August 2004, www,patientsafety.gov
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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
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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
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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”” ??
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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
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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
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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
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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
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Variable input
PasienPenyakit beratPenyakit penyertaPernah mendapatkan pengobatanUsia
Pemberi PelayananTingkat keterampilanCara pendekatan
Proses Pelayanan harus dapat mengakomodasivariabilitas yang tdk dapat dihindarkan dan tidak dapatdikontrol ini.
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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%
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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. .
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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
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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
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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.
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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
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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
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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..
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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?
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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.
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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
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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
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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 ?
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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
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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
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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
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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
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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
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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
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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.
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Step EightStep Eight
Implement & monitor the redesigned process
Design improvements should bring reduction in the CI / RPN. Ex: 30 – 50% reduction ?
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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)
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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
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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
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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
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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
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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
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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
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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®®
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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
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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 ______________________________________
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 4949
Contoh kasus 1Contoh kasus 1
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 5050
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 5151
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 5252
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 5353
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 5454
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
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 5555
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)
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 5656
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
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 5757
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”..
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 5858
Contoh kasus 2Contoh kasus 2PROSES KEGIATAN PAGI HARI MENUJU TEMPAT KERJA
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 5959
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 6060
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 6161
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 6262
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 6363
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 6464
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 6565
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 6666
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
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 6767
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
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 6868
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%?
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 6969
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
Arjaty/ IMRK/FMEA/2008Arjaty/ IMRK/FMEA/2008 7070
Team WorkTeam Work ??
?