case examples hfmeca (amkdp).pdf
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LANGKAH ANALISIS MODUS KEGAGALAN, DAMPAK & PENYEBAB
(AMKDP)/HEALTHCARE FAILURE MODE EFFECT & CAUSES ANALYSYS
(HFMECA)
1. Pilih Proses yang berisiko tinggi dan Bentuk Tim
2. Gambarkan Alur Proses
3. Diskusikan & Prioritaskan Modus Kegagalan
4. Brainstorming Dampak Modus Kegagalan5. Identifikasi Penyebab Modus Kegagalan
6. Hitung Total NPR (Nilai Prioritas Risiko)
7. Disain ulang proses / Re-disain Proses
8. Analisa & uji Proses baru9. Implementasi & Monitor Proses baru
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LANGKAH 1 : PILIH PROSES YANG BERISIKO TINGGI
Pilih Proses berisiko tinggi yang akan dianalisa.
Judul Proses :
BENTUK TIM
Ketua : ____________________________________________________________
Anggota 1. _______________ 4. ________________________________________2. _______________ 5. ________________________________________
3. _______________ 6. ________________________________________
Notulen _________________________________________
Apakah semua Unit yang terkait dalam Proses sudah terwakili ? YA / TIDAK
Tanggal dimulai ____________________ Tanggal selesai ______________________________
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LANGKAH 2A DIAGRAM PROSES
LANGKAH PROSES :
Gambarkan proses secara grafis,sesuai kebijakan & prosedur untuk setiap tindakan dan nomor dibawah ini.Jika proses terlalu kompleks,anda memilih satu langkah proses atau sub proses untuk ditindak lanjuti
Catat Sub proses untuk setiap langkah proses
Sub Proses Sub Proses Sub Proses Sub Proses Sub Proses
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LANGAKAH 2B DIAGRAM SUB PROSES
LANGKAH SUB PROSES :
Gambarkan Subproses secara grafis,sesuai kebijakan & prosedur untuk setiap tindakan dan nomor dibawah ini.Jika proses terlalu kompleks,anda memilih satu langkah Subproses untuk ditindak lanjuti
Catat Modus Kegagalan untuk setiap langkah Sub proses
Modus Kegagalan Modus Kegagalan Modus Kegagalan Modus Kegagalan Modus Kegagalan
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LANGKAH 3
BRAINSTORMING POTENSIAL MODUS KEGAGALAN & BUATPRIORITAS MODUS KEGAGALAN
543214321EHML1-255432154321
10987654321
Ranking
Modus
Kegagalan
NPR
(5X7
X8
DeteksiKontrolBandsSkor
Risi
ko
(3X
4)
ProbabilitasBahayaModus KegagalanProses
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543214321EHML1-255432154321
987654321
NPR
(5X7X8)DeteksiKontrolBandsSkor
Risiko
(3X4)
ProbabilitasBahayaDampakModus Kegagalan
LANGKAH 4
BRAINSTORMING DAMPAK MODUS KEGAGALAN
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2
Dampak
543214321EHML1-255432154321
1098765431
NPR
(6X8X9)
DeteksiKontrolBandsSkorRisiko
(4X5)
ProbabilitasBahayaPenyebabModus
Kegagalan
LANGKAH 5
IDENTIFIKASI PENYEBAB MODUS KEGAGALAN
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LANGKAH 6
HITUNG TOTAL NPR
3
NPR
Modus
Kegagalan
98765421
RankingTotal NPRNPR
Penyebab
PenyebabNPR
Dampak
DampakModus
Kegagalan
No
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LANGKAH 7
PROSES DISAIN ULANG
Ukuran
Outcome /
Pengawasan
Kinerja
Tanggal Dilaksanakan
Proses Baru
Tanggal
Diselesaikan
Penanggung
jawab
Rekomendasi
Redisain
Proses
PenyebabDampakModus
Kegagalan
Proses
987654321
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No injuryFirst aid
treatment
only with no
lost time, nor
restricted
duty injuries
nor illnesses
Medical expenses,
lost time or
restricted duty
injuries or
illness for 1 or
2 staff
Hospitalization
of 1 or 2 staff or
3 or more staff
experiencing lost
time or restricted
duty
injuries or
illnesses
Death or
hospitalization
of 3 or more
staff
Staff
Outcome
Evaluated &
First aid
treatment
No injury but
increased
LOS to
monitor
effects
MINOR
2
No injuryInjury with no
permanent loss of
function or
Evaluation &
treatment for
1 or 2 visitors(less than
hospitalizatin)
Injury with
permanent loss of
function
Or Hospitalization
of 1 or 2
visitors
Death,
hospitalization
of 3 or more
Visitor
Outcome
No injuryInjury with no
permanent loss of
function
Injury with
permanent
loss of
function
DeathPatient
Outcome
INSIGNICANT
1
MODERATE
3
MAJOR
4
CATASTROPHIC
5
SEVERITY RATINGSEVERITY RATING(Modified by IMRK)(Modified by IMRK)
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PROBABILITY(Modified by IMRK)
Very likely to occur every monthAlmost certain5
Likely to occur immediately or within a short period
(may happen several times in one year )
Likely4
Possible will occur
(may happen several times in 1 to 2 years)
Possible3
Unlikely to occur
(may happen sometimes in 2 to 5 years)
Unlikely)2
Very Unlikely to occur
(may happen sometime in 5 to 30 years)
Rare1
DefinitionDescriptionRating
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RISK GRADING MATRIX
ExtremeHighModerateLowLowRare1
ExtremeHighModerateLowLowUnlikely2
ExtremeExtremeHighModerateLowPossible3
ExtremeExtremeHighModerateModerateLikely4
ExtremeExtremeHighModerateModerateAlmost certain5
Catastrophic5
Major4
Moderate3
Minor2
Insignificant1
Potencial ConcequencesProbability
/Likelihood
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Sample Detectability Scale(Modified by IMRK)
0 out of 10
2 out 0f 10
5 out of 10
7 out of 10
10 out to 10
Probability of
Detection
Detection not possible at any pointAlmost certainnot to detect
5
Unlikely to be detectedLow likelihood4
Moderate likelihood of detectionModerate
likelihood3
Likely to be detectedHigh likelihood2
Almost always detected immediatelyCertain to detect1
DefinitionDescriptionRating
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CONTROLLABILITY
Controls and Status are unknown or Residual riskDifficult4
Controls are either not practically in place not effective, not
communicated and or not complied with no reviews undertaken or
Controls can be introduced to reduce risk to an acceptable level but
will take longer than 1 year or entail significant effort or expensive
Moderate
difficult
3
Sufficient effective controls procedures are substantially in place
for specific circumstances, communicated & are complied with
periodic reviews are conducted or
Controls can be introduced to reduce risk to an acceptable level
within 1 year or at cost
Moderate
easy
2
Comprehensive effective controls fully in place, communicated,
complied with, maintained, monitored, reviewed & tested
regularly. All that is practicable to be done is being done orRisk can be introduced 1 month / or low cost or
Easy1
DefinitionDesriptionRating