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RISK REGISTER TAHUN ..

IDENTIFIKASI RISIKO ANALISIS RISIKO


No. Sumber identifikasi Lokasi Insiden/Kejadian Sebab Insiden/Kejadian Efek / Dampak

Probabilitas
Ketegori
PENGELOLAAN

Risk Score
1. Laporan Insiden Jenis Insiden Tipe Insiden

Dampak
Risiko mis. Risk Owner / PIC
Kes Pasien / 2. Komplain RISIKO
K3 / Inf 3. Litigasi
( Mengapa Hal itu bisa terjadi )
Control dll) 4. Rapat Unit Kerja
5. Survey
6. Ronde

K
o
m
i
t
e

K
3
IDENTIFIKASI PROSES BERISIKO TINGGI

NO IDENTIFIKASI PROSES RISIKO TINGGI RISK ASSESSMENT


Probability /
Komponen Program Situasi likelihood Impact
(0-4) (1-5)

PPI

KP

K3

Komplain

Probability :
4 = Sering Terjadi
3 = Mungkin terjadi
2 = Jarang terjadi
1 = Sangat jarang
0 = Tidak mungkin terjadi

Dampak terhadap risiko


5 = Meninggal
4 = Cedera permanen
3 = Cedera reversibel / LOS memanjang
2 = Cedera ringan
1 = Tidak Cedera

Sistem Kontrol saat ini


5 = Tidak ada / None
4 = Kurang
3 = Cukup / Fair
2 = Baik
1 = Kuat / Solid
RANGKING
PRIORITAS ANALISA RISIKO
RISK ASSESSMENT RISIKO PROAKTIF

Preparedness Total Score risk FMEA / HVA


(1-5)
JUDUL PROSES
TANGGAL DIMULAI
TANGGAL SELESAI

LANGKAH 1
PEMBENTUKAN TIM
KETUA
ANGGOTA

FASILITATOR
NOTULEN

SASARAN / GOAL

Project Status
Status COMPLETE
TOTAL FAILURE MODE.

ALUR PROSES

PROSES
1 2 3 4 5 6
SUB PROSES

f
8 9
LANGKAH 3,4,5,6

MODUS KEGAGALAN DAN DAMPAK

Sub Proses: 1. .. ; Tim leader : .. ; Date : ..

Severity
Likelihood
Detection

Likelihood
Detection
Potential Potential Potential Current

RPN
Recommended

New RPN
Severity
Failure Mode Effects of Causes for Controls Action
Failure Failure

3 2 4 24 0
4 2 2 16 0
3 2 1 6 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

Sub Proses . .. ; Tim leader : .. ; Date : ..


Severity
Likelihood
Detection

Likelihood
Detection
Potential Potential Potential Current

RPN
Recommended

New RPN
Severity
Failure Mode Effects of Causes for Controls Action
Failure Failure

3 2 4 24 0
4 2 2 16 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

Sub Proses. .. ; Tim leader : .. ; Date : ..

Severity
Likelihood
Detection

Likelihood
Detection
Potential Potential Potential Current

RPN
Recommended

New RPN
Severity

Failure Mode Effects of Causes for Controls Action


Failure Failure
3 2 4 24 0
4 2 2 16 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

Sub Proses. .. ; Tim leader : .. ; Date : ..


Severity
Likelihood
Detection

Likelihood
Detection
Potential Potential Potential Current

RPN
Recommended

New RPN
Severity
Failure Mode Effects of Causes for Controls Action
Failure Failure

3 2 4 24 0
4 2 2 16 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0

Sub PRoses1. .. ; Tim leader : .. ; Date : ..

Severity
Likelihood
Detection

Likelihood
Detection
Potential Potential Potential Current

RPN
Recommended

New RPN
Severity

Failure Mode Effects of Causes for Controls Action


Failure Failure
3 2 4 24 0
4 2 2 16 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
Severity

Detection
RPN
Likelihood
Potential Failure Potential Potential Current
Mode Effects for Causes of Controls
Failure Failure

3 2 4 24
4 2 2 16
3 2 1 6
3 2 4 24
4 2 2 16
Recommended Action

Reassessment Date
Likelihood
Severity

Detection

New RPN
Action Plan :
Failure CAUSE Recommen Action(s) to Implement Implemen Implementatio Resourc Resource Evidence Monitoring Sign- Sign-
Mode dation(s) achieve ation by tation by n of the place e required of & off by off Date
recommendati Whom when (Where) required (Money) completio evaluation
ons (How) (Time) n arrangemen
ts

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