Konsep dan penerapan

Manajemen risiko di
rumah sakit
Dr. Danny Widjaja, MM, FISQua
 Curriculum Vitae
dr. Danny Widjaja, MM FISQua
RIWAYAT PENDIDIKAN
RIWAYAT PELATIHAN
1999 Faculty of Medicine Diponegoro University
2008 Patient Safety & Hospital Risk Management Workshop, KKPRS, Ministry of Health
2012 Master of Hospital Administration from Pasundan University
2020 Konsultan Manajemen Kesehatan (Health Management Consultant) – KKNI level 7 2009 Joint Commission International (JCI) Practicum on Quality Improvement and Accreditation, Seoul,
South Korea
2020 Fellowship, International Society for Quality in Healthcare (FISQua)
2013 WHO Hand Hygiene Audit Course, Singapore
2021 Council of Six Sigma Certification (CSSC) – Certified Lean Six Sigma Black Belt
2018 Joint Commission International (JCI) – Quality Management & Patient Safety Programme, Jakarta

RIWAYAT PEKERJAAN
2019 KARS – Workshop Quality Improvement & Patient Safety (PMKP)
Jan 2006 – Agt 2008 Santosa Hospital, Bandung Central – Kepala IGD
2020 Fellowship ISQUA
Agt 2008 – Agt 2011 Santosa Hospital, Bandung Central - COO + Wk KetuaTim Akreditasi JCI

Sep 2011 – Jun 2015 Siloam Hospitals Lippo Cikarang – Direktur Medis RIWAYAT ORGANISASI

Sep 2012 – Apr 2017 Siloam Hospitals Lippo Cikarang - CEO 1999 Ikatan Dokter Indonesia (IDI)

Apr 2017 – Jun 2018 Siloam Hospitals TB Simatupang - CEO 2019 Ikatan Konsultan Kesehatan Indonesia (IKKESINDO)

Jun 2018 – Jan 2019 Siloam Hospitals – Regional CEO West Mature Region 2020 International Society of Quality Healthcare (ISQua)

2021 LAM-KPRS – Sekretaris Kompartemen Manajemen Survei & Akreditasi

Feb 2019 – now Siloam Hospitals Group – Quality & Risk Div Head

2
 Lingkup Risiko yang tercantum dalam standar akreditasi RS 2022
• Tugas representasi pemilik : Melakukan pengkajian laporan
Manajemen Risiko setiap 6 (enam) bulan sekali dan memberikan
umpan balik perbaikan yang harus dilaksanakan dan hasilnya di
evaluasi kembali pada pertemuan berikutnya secara tertulis.
• Tanggung jawab Direktur : Melaporkan hasil pelaksanaan program
manajemen risiko kepada Representasi pemilik/Dewan Pengawas
setiap 6 (enam) bulan
• Program prioritas peningkatan mutu, meliputi Manajemen Risiko
(TKRS 5 elemen a)
• Manajemen Risiko dalam rantai perbekalan / supply chain (TKRS
7.1)
• Program Manajemen Risiko di tingkat unit kerja (TKRS 9 elemen c)
• Program Manajemen Risiko terintegrasi tingkat rumah sakit (TKRS
14, PMKP 11)
• Manajemen Risiko untuk staf (KPS 9)
• Partisipasi staf dalam program Manajemen Risiko (KPS 16, KPS 19)
• Manajemen Risiko terkait fasilitas, sarana dan prasarana
(MFK secara keseluruhan, MFK 3, MFK 9, MFK 10)
• Manajemen Risiko terkait infeksi (PPI secara keseluruhan,
PPI 2, PPI 3, SKP 5)
• Manajemen Risiko terkait koordinasi, kesinambungan
pelayanan dan transportasi pasien (AKP)
• Manajemen Risiko (klinis) dalam kaitannya dengan
pengkajian pasien, termasuk pemeriksaan laboratorium,
radiologi (PP, SKP 6, SKP 6.1)
• Manajemen Risiko (klinis) terkait pemberian pelayanan,
terutama pelayanan risiko tinggi dan pasien berisiko tinggi
(PAP, HPK, SKP 1, SKP 2)
• Manajemen Risiko Perioperatif (PAB, SKP 4)
• Manajemen Risiko terkait pengelolaan obat (PKPO, SKP 3,
SKP 3.1)
• Manajemen Risiko terkait informasi (MRMIK)
3
 Tujuan Pembelajaran

1. Peserta memahami konsep manajemen risiko

2. Peserta memahami kerangka manajemen risiko di rumah sakit
3. Peserta mampu melakukan FMEA

1. Australian/New Zealand AS/NZS 4360:2004 – Risk Management Standard

2. Clinical Risk Management Guidelines for Western Australian Health System

4
Kerangka pembahasan
1. Safer Healthcare - Charles Vincent & René Amalberti (2015)
2. What is Risk in Healthcare? – Catalyst. NEJM (2018)
3. Kerangka kerja manajemen risiko (Risk Management
Framework) dan penerapannya di rumah sakit

5
1. Safer Healthcare - Charles Vincent & René Amalberti (2015)
2. What is Risk in Healthcare? – Catalyst. NEJM (2018)
3. Kerangka kerja manajemen risiko (Risk Management
Framework) dan penerapannya di rumah sakit

6
Safer Healthcare
• The Ideal and the Real: Five Levels of Care
• Approaches to Safety: One Size Does Not Fit All
• The Consequences for Incident Analysis
• Strategies for Safety

Charles Vincent & René Amalberti

Oxford and Paris. August 2015

7
The Ideal and the Real: Five Levels of Care
1. Level 1 corresponds to optimal care envisaged by standards (though truly
optimal care can never be encapsulated in standards). These standards are set
out by national and professional organizations and represent a consensus on
what can be regarded as the optimum care achievable within current cost
constraints. This level provides a shared ideal reference of excellent care,
although it is seldom fully achieved across an entire patient journey.
2. Level 2 represents a standard of care which experts would judge as both
providing a good outcome for the patient and also achievable in day-to-day
practice. The care is of good standard and the outcome is good, even though
there may be minor variations and problems. Any deviations from best practice
are relatively unimportant in the overall care provide to the patient.
3. Level 3 represents the first level where the safety of the patient may be
compromised. We consider, for reasons given above, that a considerable
amount of the healthcare that patients receive falls broadly into this category. At
this level there are frequent deviations from best practice which occur for a
wide variety of different reasons and are a potential threat to patients. There
may for example not be a timely monitoring of anticoagulation level after
prescription of heparin. This level has been previously described as the ‘illegal
normal’

8
The Ideal and the Real: Five Levels of Care

4. Level 4 represents a deviation from standards which is sufficient to produce

avoidable harm. For example, a 68-year-old patient undergoes a
cholecystectomy and contracts a urinary catheter infection after surgery.
Analysis of the event showed that the catheter was not checked regularly and
was left in place too long. This was a clear deviation from expected care.
However, treatment was rapidly instituted, and the infection was under full
control after 10 days. The patient suffered avoidable harm and had to stay in
hospital an additional week but then recovered completely.
5. Level 5 refers to care that is poor over a longer period and places the patient at
risk of substantial and enduring harm. For instance, if in the case described
above, the patient not only contracted the infection, but it was then not
recognized and not treated effectively. This would result in at best a very
prolonged recovery and increased frailty but also a potentially fatal outcome.

9
The Ideal and the Real: Five Levels of Care

10
Approaches to Safety : One Size Does Not Fit All

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Approaches to Safety : One Size Does Not Fit All
• Safety is approached very differently in different environments. In some environments and professions risk
is embraced, in some it is managed and in others it is controlled.

• We distinguish three classes of safety models: The three models reflect the degree to which
the environment is unstable and unpredictable.
• an ultra-adaptive approach associated with embracing risks, Very high levels of safety can only be achieved
• the high reliability approach managing risks, and in very controlled environments

• the ultra-safe approach which relies heavily on avoiding risks.

• Intervention strategies must be adapted to these models, giving importance to experts in ultra-adaptive contexts,
to teamwork in HRO contexts, and to standardization, oversight and control in ultra-safe contexts.
• Healthcare has many different types of activity and clinical settings. Areas of highly standardized care, such as
radiotherapy, conform to an ultra-safe model. In contrast much ward care corresponds to an intermediate model
of team-based care, employing a combination of standards and protocols, professional judgement and flexibility.

12
Approaches to Safety : One Size Does Not Fit All
• Some clinical activities such as emergency surgery are necessarily more adaptive. The work may be scheduled but
there is considerable hour-to hour adaptation due to the huge variety of patients, case complexity, and
unforeseen perturbations.
• All clinical areas, no matter how adaptive, rely on a bedrock of core procedures; adaptive is a relative term not
an invitation to abandon all guidelines and go one’s own way.

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The Consequences for Incident Analysis
Every high-risk industry devotes considerable time and resource
to investigating and analyzing accidents, incidents and near
misses. Such industries employ many other methods for
assessing safety, but the identification and analysis of serious
incidents and adverse events continues to be a critical stimulus
and guide for safety improvement.
Analyses of safety issues always require review of a range of
information and recommendations should generally not be made
on the basis of a single event. Nevertheless, an effective overall
safety strategy must in part be founded on an understanding of
untoward events, their frequency, severity, causes and
contributory factors.
James Reason’s – Swiss Cheese Model

14
The Consequences for Incident Analysis
We previously extended Reason’s model and adapted it for
use in healthcare, classifying the error producing conditions
and organizational factors in a single broad framework of
factors affecting clinical practice (Vincent et al. 1998 ;
Vincent 2003 ).
The ‘seven levels of safety’ framework describes the
contributory factors and influences on safety under seven
broad headings: patient factors, task factors, individual
staff factors, team factors, working conditions,
organizational factors and the wider institutional context

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Strategies for Safety

16
Strategies for Safety

17
1. Safer Healthcare - Charles Vincent & René Amalberti (2015)
2. What is Risk in Healthcare? – Catalyst. NEJM (2018)
3. Kerangka kerja manajemen risiko (Risk Management
Framework) dan penerapannya di rumah sakit

18
What is Risk in Healthcare? – Catalyst. NEJM (2018)

Risk management in healthcare comprises the clinical and

administrative systems, processes, and reports employed to
detect, monitor, assess, mitigate, and prevent risks.

By employing risk management, healthcare organizations

proactively and systematically safeguard patient safety as well
as the organization’s assets, market share, accreditation,
reimbursement levels, brand value, and community standing

What Is Risk Management in Healthcare? (nejm.org) https://catalyst.nejm.org/doi/full/10.1056/CAT.18.0197

19
Enterprise Risk Management (ERM)
Evolution of Healthcare Enterprise Risk Management (ERM)
To expand the role of risk management across the organization,
hospitals and other healthcare facilities are adopting a more holistic
approach called Enterprise Risk Management. ERM includes traditional
aspects of risk management including patient safety and medical liability
and expands them with a “big picture” approach to risk across the
organization.

ERM encompasses eight risk domains:

1.Operational
2.Clinical & Patient Safety
3.Strategic
4.Financial
5.Human Capital
6.Legal & Regulatory
7.Technological
8.Environmental- and Infrastructure-Based Hazards.
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Key Components of Performing
Risk Management in Healthcare
1. Identify Risk
Since risk management involves managing uncertainty and new risk is constantly emerging, it is challenging to
recognize all the threats a healthcare entity faces. However, through the use of data, institutional and industry
knowledge, and by engaging everyone — patients, employees, administrators, and payers—healthcare risk
managers can uncover threats and potentially compensatory events that otherwise would be hard to anticipate.
2. Quantify & Prioritize Risk
Once identified, it is vital to score, rank, and prioritize risks based on their likelihood and impact of occurrence
and then allocate resources and assign tasks based on these measures. To accomplish this, risk matrices and
heat maps can be deployed that will also help to visualize risks and promote communication and collaborative
decision-making.

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3. Investigate & Report Sentinel Events
Coined by the Joint Commission, Sentinel Events are “any unanticipated event in a healthcare setting resulting in
death or serious physical or psychological injury to a patient or patients, not related to the natural course of the
patient’s illness.” When a sentinel event occurs, quick response and thorough investigation address immediate
patient safety issues and reduce future risk. Having an established plan in place promotes calm and measured
response and transparency by staff and ensures that corrective actions can be implemented and evaluated. Sentinel
events are not always the result of errors. However, achieving transparency and thorough evaluation requires
healthcare organizations to establish an atmosphere of respect, trust, and cooperation between staff and
leadership.
4. Perform Compliance Reporting
As with the Joint Commission, Federal, state, and other oversight bodies mandate reporting of certain types of
incidents including sentinel events, medication errors, and medical device malfunctions. Incidents such as wrong-
site or patient surgery, workplace injuries, medication errors, etc. need to be documented, coded, and reported.

22
5. Capture & Learn from Near Misses & Good Catches
When mistakes or adverse events are avoided due to luck or intervention, “near misses” and “good catches” occur.
These are often the best way to identify and prevent risk. Healthcare providers should develop a culture that
encourages reporting so that prevention measures and best practices can be instituted.
6. Think Beyond the Obvious to Uncover Latent Failures
Active failures are obvious and easily-identified — when a nurse gives the wrong medication dose to a patient for
example. Latent failures, on the other hand, are often hidden and only uncovered through analysis and critical
examination. Did poor lighting make it hard to read the patient’s chart? Was the nurse rushing because he had too
many high-acuity patients? When exploring the causes of an unfavorable episode, consider underlying and less-
readily-apparent reasons.
7. Deploy Proven Analysis Models for Incident Investigation
Models for analyzing accidents are used to understand latent failures and causes as well as relationships among
risks. For example, understaffing and fatigue often lead to medical errors. Applying well-established models
improves risk management effectiveness and efficiency.. FMEA or Failure Mode and Effects Analysis, as well as Root
Cause Analysis, are deployed and involve detailed frameworks to help uncover the causes and effects of medical
mistakes.
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9. Invest in a Robust Risk Management Information System (RMIS)
Multiple platforms for reporting and managing risk are on the market. These systems provide tools for documenting
incidents, tracking risk, reporting trends, benchmarking data points, and making industry comparisons. Reports can
be generated for losses, incidents, open claims, and lost work time for injured employees to name a few. RMIS can
greatly enhance risk management by improving performance through available and reliable systems while providing
overall cost reduction by automating routine tasks.
10. Find the Right Balance of Risk Financing/Transfer/Retention
Risk financing involves an organization’s methods for efficiently and effectively funding loss that results from risk. It
includes risk transfer usually through insurance policies and risk retention such as self-insurance and captive
insurance.

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1. Safer Healthcare - Charles Vincent & René Amalberti (2015)
2. What is Risk in Healthcare? – Catalyst. NEJM (2018)
3. Kerangka kerja manajemen risiko (Risk Management
Framework) dan penerapannya di rumah sakit

25
 Tahap pertama ini adalah menetapkan / mendefinisikan batasan-batasan dari rumah
sakit di mana proses manajemen risiko akan diberlakukan, aktivitas pengendalian
risiko yang akan dilakukan dan kemungkinan dampak yang mungkin timbul dari
pengaruh internal maupun eksternal
* Scope of Risk Management Program – Rumah Sakit / Unit Kerja / Pelayanan /
Proses
Lingkup Risiko
Environmental &
Clinical Operational
Strategic & Financial Legal & Regulatory Human Capital Infrastructure based
& Patient Safety & Technological Hazard

 Competition  Compliance with  Clinical Risk from  Patient Safety  Supply Chain  Business
Law & Regulations Procedures Risks  Hazard materials Interruption
 Profitability (Permit &  Infection Related  Communications  Waste
 Cash Flow (AR) Licenses) Risk  Customer Management  Emergency &
 Asset Loss  Hospital Standard  Equipment Satisfaction  Asset breakdown Disaster (Fire,
 Business Model  Malpractices malfunction  Workload / Equipment Flood,
 Expansion  Lawsuit  Patient related Efficiency failure Earthquake,
 Fraud, illegal acts, risk (allergy, age,  Competency of  Cyber securities Outbreak, Strike,
corruption comorbidities, etc) doctors / nurses  Technology etc)
 Occupational Failure
Disease  Radiation Risk
 Ethical risks
 Culture of Safety

Metode untuk monitoring & review yang dapat digunakan antara lain:
1. External (Akreditasi, ISO, External auditor, Government)
2. Internal (Komite Mutu, Internal auditor)
3. Review rutin dari kebijakan rumah sakit, Pedoman/Panduan, SOP, dan Strategi
4. Evaluasi program manajemen risiko dan pengelolaan risiko (termasuk program
manajemen risiko PPI, MFK, dan lain-lain program keselamatan, seperti di lab maupun
radiologi) oleh pimpinan rumah sakit secara berkala.

26
 Lingkup Risiko yang tercantum dalam standar akreditasi RS 2022
• Tugas representasi pemilik : Melakukan pengkajian laporan Manajemen Risiko setiap 6 (enam)
bulan sekali dan memberikan umpan balik perbaikan yang harus dilaksanakan dan hasilnya di
evaluasi kembali pada pertemuan berikutnya secara tertulis.
• Tanggung jawab Direktur : Melaporkan hasil pelaksanaan program manajemen risiko kepada
Lingkup Risiko Representasi pemilik/Dewan Pengawas setiap 6 (enam) bulan
• Program prioritas peningkatan mutu, meliputi Manajemen Risiko (TKRS 5 elemen a)
• Manajemen Risiko dalam rantai perbekalan / supply chain (TKRS 7.1)
• Program Manajemen Risiko di tingkat unit kerja (TKRS 9 elemen c)
• Program Manajemen Risiko terintegrasi tingkat rumah sakit (TKRS 14, PMKP 11)
• Manajemen Risiko untuk staf (KPS 9)
• Partisipasi staf dalam program Manajemen Risiko (KPS 16, KPS 19)
• Manajemen Risiko terkait fasilitas, sarana dan prasarana (MFK secara keseluruhan, MFK 3, MFK 9,
MFK 10)
• Manajemen Risiko terkait infeksi (PPI secara keseluruhan, PPI 2, PPI 3, SKP 5)
• Manajemen Risiko terkait koordinasi, kesinambungan pelayanan dan transportasi pasien (AKP)
• Manajemen Risiko (klinis) dalam kaitannya dengan pengkajian pasien, termasuk pemeriksaan
laboratorium, radiologi (PP, SKP 6, SKP 6.1)
• Manajemen Risiko (klinis) terkait pemberian pelayanan, terutama pelayanan risiko tinggi dan
pasien berisiko tinggi (PAP, HPK, SKP 1, SKP 2)
• Manajemen Risiko Perioperatif (PAB, SKP 4)
• Manajemen Risiko terkait pengelolaan obat (PKPO, SKP 3, SKP 3.1)
• Manajemen Risiko terkait informasi (MRMIK)

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Lingkup Risiko
• Risiko Operasional adalah risiko yang terjadi saat rumah sakit memberikan pelayanan
kepada pasien baik klinis maupun non klinis.
• Risiko klinis yaitu risiko operasional yang terkait dengan pelayanan kepada pasien
(keselamatan pasien) meliputi risiko yang berhubungan dengan perawatan klinis dan
pelayanan penunjang seperti kesalahan diagnostik, bedah atau pengobatan.
• Risiko non klinis yang juga termasuk risiko operasional adalah risiko PPI (terkait
pengendalian dan pencegahan infeksi misalnya sterilisasi, laundry, gizi, kamar jenazah
dan lain-lainnya), risiko MFK (terkait dengan fasilitas dan lingkungan, seperti kondisi
bangunan yang membahayakan, risiko yang terkait dengan ketersediaan sumber air dan
listrik, dan lain lain. Unit klinis maupun non klinis dapat memiliki risiko yang lain sesuai
dengan proses bisnis/kegiatan yang dilakukan di unitnya. Misalnya unit humas dapat
mengidentifikasi risiko reputasi dan risiko keuangan;
• Risiko keuangan;
• Risiko reputasi (citra rumah sakit yang dirasakan oleh masyarakat);
• Risiko strategis (terkait dengan rencana strategis termasuk tujuan strategis rumah sakit);
dan
• Risiko kepatuhan terhadap hukum dan regulasi.

28
 Metode-metode identifikasi risiko dapat dilakukan di antaranya melalui:
a. Laporan insiden – repeated incidents, near misses (KNC), no harm incidents
Penilaian Risiko (Risk Assessment) b.
(KTC), adverse events (KTD) & Sentinel Events
Komplain (pasien, staf, pengunjung)
c. Inspeksi (Ronde manajemen, facility tour)
d. Temuan Audit (External & Internal)
e. HVA (Hazard Vulnerability Analysis)
f. HSI (Hospital Safety Index)
g. ICRA, PCRA, FSRA
h. Hasil identifikasi risiko dari staf RS
i. Lain-lain

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 CONSEQUENCE
Serious Major Moderate Minor Minimum
(5) (4) (3) (2) (1)
LIKELIHOOD

Penilaian Risiko (Risk Assessment)

Frequent 5x5 = 5x4 = 5x3 = 5x2 = 5x1 =
(5)
25 20 15 10 5
Likely 4x5 = 4x4 = 4x3 = 4x2 = 4x1 =
(4) 20 16 12 8 4
Possible 3x5 = 3x4 = 3x3 = 3x2 = 3x1 =
(3) 15 12 9 6 3
Unlikely 2x5 = 2x4 = 2x3 = 2x2 = 2x1 =
(2) 10 8 6 4 2
Rare 1x5 = 1x4 = 1x3 = 1x2 = 1x1 =
(1) 5 4 3 2 1
Nilai Klasifikasi Risiko
13 - 25 High Risk
9 - 12 Medium Risk
1-8 Low Risk

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 I. Alternatif opsi pengelolaan risiko
Pengelolaan Risiko 1.1. Accepted
1.2. Not Accepted
a. Avoid (Menghindari)
b. Reducing (Mengurangi) – mengurangi Likelihood atau
Consequences
c. Transferring (Mengalihkan) – termasuk insuring, outsourcing,
rental, contract service
d. Partially Retaining (tetap diterima (sebagian), dengan menyiapkan
contingency)
II. Evaluasi pilihan pengelolaan risiko
III. Menyiapkan rencana pengelolaan
Setelah dipilih upaya pengelolaan risiko, disusun suatu rencana penerapan.
Rencana ini meliputi minimal:
a. Apa yang akan dilakukan (what)
b. Bagaimana cara melakukan (how)
c. Apa resource yang diperlukan, alat/biaya/SDM, dll
d. Siapa yang bertanggung jawab (who)
e. Bagaimana timeline (kapan mulai, kapan selesai) (when)
f. Di mana lokasi action plan tersebut akan dilakukan (where)
g. Bagaimana proses monitoring dan evaluasi dari program ini?
h. Siapa yang memonitor?
i. Bagaimana cara monitor?
j. Seberapa sering dimonitor?

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Summary
1. Perlu ada perubahan paradigma dalam manajemen risiko dalam pelayanan kesehatan.
• Dalam pelayanan, ada berbagai tingkatan yang terjadi (contoh : 5 level of care) yang
membedakan tingkatan risiko terhadap pasien, dan masing-masing memiliki upaya
pengelolaan yang berbeda
• Dalam mengelola risiko, tidak ada satu pendekatan tanggal yang dapat diterapkan ke semua
pelayanan di RS. Pendekatan harus dilakukan sesuai tingkat risiko dari pelayanan tersebut.
(Approaches to Safety: One Size Does Not Fit All)
• Pentingnya belajar dari insiden untuk mengurangi risiko terhadap pasien
• Ada banyak strategi yang berbeda yang dapat diterapkan pada berbagai level yang berbeda
untuk mengelola risiko.
2. 8 Area Risiko di pelayanan kesehatan
3. Kerangka kerja manajemen risiko dan contoh penerapannya di rumah sakit

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Edward Aloysius Murphy Jr. (January 11, 1918 – July
17, 1990[1]) was an American aerospace
engineer who worked on safety-critical systems.
He is best known for his namesake Murphy's law,
which is said to state, "Anything that can go wrong
will go wrong".

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Terima Kasih

34
Failure Mode & Effect Analysis
(FMEA) / Analisa Modus
Kegagalan & Dampak (AMKD)

FMEA adalah suatu metode pro aktif untuk

mengurangi risiko. FMEA dilakukan terhadap
proses-proses yang diidentifikasi mengandung
risiko. Di mana dengan melakukan perubahan-
perubahan dari proses (re-design process) maka
diharapkan risiko yang terkandung dalam proses
tersebut dapat diminimalisasi

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 Tahap – Tahap FMEA
1. Pilih proses yang akan diperbaiki menggunakan FMEA.
FMEA berfungsi dengan baik pada proses yang tidak memiliki banyak sub-proses
Jika akan mengevaluasi proses besar dan kompleks, sebaliknya di pecah menjadi proses yang lebih kecil.
Contoh : Untuk Medication Management, bisa dipecah menjadi medication ordering, dispensing, and administration
processes.

Order Prepare Dispensing Storage Administration Monitoring

Dokter jaga Tulis di Dokter jaga menyalin Catatan pemberian

Dr Spesialis beri
CPPT dan Lakukan catatan pemberian obat dikirim ke
instruksi verbal
‘Read Back’ obat Farmasi

Patient Safety Essentials Toolkit | IHI - Institute for Healthcare Improvement

36
 Tahap – Tahap FMEA
1. Pilih proses yang akan diperbaiki menggunakan FMEA.

37
 Tahap – Tahap FMEA
2. Bentuk Tim Multi Disiplin.
Pastikan setiap orang yang terlibat di setiap tahap terlibat dalam tim.
Beberapa orang boleh merupakan anggota ad-Hoc. (Hanya ikut pada diskusi tertentu saja)
Misalnya : jika RS melibatkan runner untuk mengantar obat dari Farmasi ke unit perawatan, maka runner tersebut
perlu dilibatkan saat diskusi tentang proses pengantaran tersebut.

3. Pastikan Tim memiliki daftar step dalam proses yang akan dibahas dalam FMEA.
Tim perlu menyepakati daftar step dalam proses yang akan dibahas dalam FMEA ini.

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 Tahap – Tahap FMEA
Likelihood of Likelihood of Risk Profile
Severity Actions to Reduce
No Steps in the Process Failure Mode Failure Causes Failure Effects Occurrence Detection Number
(1-10) Occurrence of Failure
(1-10) (1-10) (RPN)

• Failure Mode [What could go wrong?]: List anything that could go wrong during that step in the process
• Failure Causes [Why would the failure happen?]: List all possible causes for each of the failure modes you’ve identified
• Failure Effects [What would be the consequences of the failure?]: List all possible adverse consequences for each of the failure modes
identified
• Likelihood of Occurrence (1–10): On a scale of 1-10, with 10 being the most likely, what is the likelihood the failure mode will occur?
• Likelihood of Detection (1-10): On a scale of 1-10, with 10 being the most likely NOT to be detected, what is the likelihood the failure will
NOT be detected if it does occur?
• Severity (1-10): On a scale of 1-10, with 10 being the most likely, what is the likelihood that the failure mode, if it does occur, will cause
severe harm?
• Risk Profile Number (RPN): For each failure mode, multiply together the three scores the team identified (i.e., likelihood of occurrence x
likelihood of detection x severity). The lowest possible score will be 1 and the highest 1,000. To calculate the RPN for the entire process,
simply add up all of the individual RPNs for each failure mod
• Actions to Reduce Occurrence of Failure: List possible actions to improve safety systems, especially for failure modes with the highest RPNs
39
 Tahap – Tahap FMEA

Risk
Likelihood of Likelihood of Risk Profile Likelihood of Likelihood of
Steps in the Severity Actions to Reduce Severity Profile
No Failure Mode Failure Causes Failure Effects Occurrence Detection Number PIC Occurrence Detection
Process (1-10) Occurrence of Failure (1-10) Number
(1-10) (1-10) (RPN) (1-10) (1-10)
(RPN)

40
Terima Kasih

41