16/12/2013

Hazard, Barrier, Target Analysis

Hazard Barrier Target

Analisis penghalang
BARRIER ANALYSIS
High
Dog Fence Child

BARRIER
• Barrier: penghalang agar adverse event
tidak terjadi

• Instrumen untuk mengidentifikasi barier

keselamatan untuk mencegah kejadian yg
tak diharapkan

1
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ANALISIS PENGHALANG/
ACCIDENT

• Penghalang atau kontrol untuk mencegah terjadinya bahaya

• Analisa penghalang didesain untuk mengidentifikasi :
1. Penghalang mana yang seharusnya untuk mencegah insiden
2. Mengapa penghalang gagal ?
3. Penghalang apa yang dapat digunakan untuk mencegah insiden
terulang kembali ?

BARRIER
Ada 4 tipe penghalang:
1. Penghalang Fisik
Makin keatas (mendekati accident), barrier semakin kecil
2. Penghalang Natural
3. Penghalang Tindakan manusia
4. Penghalang Administrasi

IDENTIFIKASIKAN BARRIER YANG

KAPAN DIGUNAKAN MUNGKIN DIPASANG
BARRIER ANALYSIS
Hazard Barrier Target
• STAND ALONE
• SETELAH DILAKUKAN INVESTIGASI
RCA
1. …
2. …
Dog Child
3. …
• SKALA EFEKTIFITAS (1 – 6)
– Skala 1: paling efektif
– Skala 6: paling tidak efektif

2
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APA YANG HARUS DILAKUKAN AGAR

ANAK TIDAK DIGIGIT ANJING
Hazard: Anjing Galak
Target: Anak KEcil

No. BARRIER RATING (1-6)

1
2

3
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4
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ANALISIS PENGHALANG /
BARRIER ANALYSIS APA YANG HARUS DILAKUKAN AGAR
Hazard Barrier Target TIDAK SALAH SISI OPERASI

Hazard: Operasi pada sisi yang salah

Target: Pasien

No. BARRIER RATING (1-6)

1
2

Sumber potensial Pasien

Melindungi target dari
menyebabkan harm
/ kerugian hazard

5

Problem: tourniquet applied to incorrect leg by consultant surgeon and assistant
What
barriers/controls/defences
were in place?
Guideline states that the
surgeon or assistant should
see and check all patients
including the operation site
mark prior to the procedure.
Correct and appropriate
marking of operative site.
16/12/2013
Barrier Analysis
(Wrong Site Surgery Case) TUGAS ( 15 menit)
KASUS 1: Insiden Angiografi
Did the Why did the barrier/control/defence fail and what
barrier/co was its impact?
ntrol/
Berdasarkan:
defence • Laporan kejadian RS. Sejahtera Medika
work?
• Rekam medis Kasus Tuan Budi.S
No 1. Guideline did not state when and whom should
do this. Task was partially completed by assistant
and consultant, but communication and
• Tiap Kelompok bertugas:
information transfer was incomplete.
2. Consultant prefers to see his patients pre- 1. Menetapkan Hazard
operatively the day before procedure and mark
the operative site himself. However, due to late
admission the operative site was marked by an
2. Menetapkan Barier yang mungkin
untrained SHO.
3. Menentukan skala efektifitas untuk setiap
No 1. SHO applied mark via a skin pencil in an
unusual site, which would not be immediately barier
visible to the surgeon. The SHO had not been
trained in this procedure, nor was their a
guideline giving instruction on how to complete
this task.
2. Compression socks obscured site mark.