LAPORAN FAILURE MODE EFFECT ANALYSIS (FMEA)
IDENTIFIKASI DAN PENGURANGAN RISIKO DALAM PELAYANAN LABORATORIUM DI RS PKU MUHAMMADIY MUHAMMAD IYAH AH YOGYAKART YOGYAKARTA DENGAN METODE FAILURE MODE EFFECT ANALYSIS
Oleh :
TIM PENINGKATAN MUTU DAN KESELAMATAN PASIEN
RS PKU MUHAMMADIYAH YOGYAKARTA 2015
BAB I PENDAHULUAN
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B T,,!% 1 Me%*%&$!"$!%$e'el!!"!% !'*e% +!l! el!-!%!% l!/#!"#*, 2 Me%&,#!%&*$e!+*!% -!%& /e#"e%'* e###!$*/!"$e&!&!l!%'*'"e -!%& /e#l!$, 9 Me%*%&$!"!% ,", +!% $e,!'!% !'*e% "e#h!+! el!-!%!% l!/#!"#*,
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BAB II FAILURE MODE EFFECT ANAL!I! (FMEA)
A DEFINISI Failure Mode Effect Analysis (FMEA) !+!l!h ',!", !l!" ,", ,%",$ e%&$!* ',!", #'e+,# 'e3!#! #*%3*. +!% e%&e%!l*
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B LANGKAH
L!%&$!h 2 : Me%-,',% flo#$c%art el!-!%!%
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C LANGKAH 1 : MENCARI PROSES YANG BERESIKO TINGGI DAN MEMBENTUK TIM 1 P#'e' Be#*'*$ Y!%& D**l*h U%",$ D*!%!l*'*' PELAYANAN LABORATORIUM
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D LANGKAH 2 : MENYUSUN FLO*$C+ART PELAYANAN
E LANGKAH 9 : IDENTIFIKASI EFEK KEGAGALAN (FAILURE MODE ) F!'eT!h! Pe%+!"!#!%
Failure Mode S,#!" e#*%"!!% "*+!$ +**'* le%&$!
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F LANGKAH : MENETAPKAN TINGKAT KEPARAHAN DARI EFEK KEGAGALAN DENGAN SKORING ( RI!, 'RIORIT NUM-ER) NO
FAILURE MODE
OCC
SE
DET
RPN
PRIORITAS
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A
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LANGKAH 5 : IDENTIFIKASI AKAR PENYEBAB MASALAH ( FI!+$-ONE MET+ODE ) 1 HASIL KRITIS TIDAKTERLAMBAT DILAPORKAN
PROCESS
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FASILITAS Auto$caliration e%&h!/!" h!'*l
S,l- l*'"#*$ "*+!$ e!+!* Al!" #,'!$ e%+!+!$ L!/#!"#* , #,,$!% $e l,!# $,#!%& #e'%'*
FAKTOR FAKTOR
PETUGAS
LINGKUNGAN KER?A
ORGANISASI
MANA?EMEN
PEMERIKSAAN HASIL KRITIS TIDAKTERLAMBAT DILAPORKAN
T*+!$ !+! e%!%&&,%&<!8!/ h!'*l ee#*$'!!% $#*"*' Bel, !+! %e;
2 KESALAHAN PENEMPELAN LABEL IDENTITAS PASIEN PADA SURAT PERMINTAAN
PROSES
FASILITAS
Ce$ +!% #*3e$ !%"!# e",&!' /el, /e#!l!%
T*+!$ !",h "e#h!+! SPO
H!/!"!% $,%*$!'* L!+ !'*e%
T,l*'!% "*+!$
"*%&&*
el!' PETUGAS
PASIEN
FAKTOR LINGKUNGAN KER?A
T*+!$ !+! #*%"e# l!/el /!#3+e +* ,%*" e%"*%&
S,e#;*'* +* l,!# ! $e#! $,#!%& "*!l A#e! $e#! "*+!$ #!* FAKTOR ORGANISASI MANA?EMEN
Ce"!$!% l!/el (/!#3+e) "e#/!"!'
KESALAHAN LABEL IDENTITAS PASIEN
Bel, !+! !,+*" "*%&$!" $e!",h!% $e"e!"!% *+e%"**$!'*
Ke"e!"!% *+e%"**$!'* /el, e/,+!-!
9 SUMBER DAYA LISTRIK TIDAK MEMADAI
FASILITAS
PROSES
Peel*h!#!!% *%'"!l!'* l*'"#*$ /el, !$'*!l
Peel*h!#!!% ',/e# l*'"#*$ 3!+!%&!% (UPS) /el, +*l!$,$!% #,"*%
Se'**$!'* +!% $e/,",h!% S,/e# l*'"#*$ ,"!! 3!+!%&!% /el, "e#*+e%"**$!'*
UPS !"*"*+!$ /e#,%&'*. "*+!$ 'e&e#! +*&!%"*
SUMBER LISTRIK TIDAK MEMADAI
Bel, !+! e",&!' -%& +*",%,$ eel*h!#! UPS
PETUGAS
O;e#he!"*%& +* !#e! &e%'e" O;e#he!"*%& +* !#e! l!/#!"#*, FAKTOR LINGKUNGAN KER?A
T*+!$ !+! $,%*$!'* ee$"* +e%&!% ,%*" eel*h!#!!%$e"*$! !+! e%!/!h!% !l!" /,",h l*'"#*$ FAKTOR ORGANISASI MANA?EMEN
Bel, !+! e/!&*!% ",&!' el!' *h!$ -!%& el!$,$!% eel*h!#!!% UPS
H LANGKAH = : DESAINRANCANGAN ULANG PROSES NO FM PRIORITAS 1 Pee#*$'!!% +!% h!'*l $#*"*' "*+!$ "e#l!/!" +*l!#$!%
2
Ke'!l!h!% e%eel!% l!/el *+e%"*"!' !'*e% !+! ',#!" e#*%"!!%
RANCANGAN ULANGPERBAIKAN TARGET AKTU 1 Me%*%&$!"$!% $e+*'*l*%!% e%&*'*!% /,$, 15 Ne/e# 2015 $h,',' l!#!% h!'*l $#*"*' 2 E+,$!'* )e",&!' l!/#!"#*, (TLM) 25 O$"/e# 2015 e%"*%&%-! 'e&e#! el!#$!% h!'*l $#*"*' (e#"e,!% e/,!"!% '"e#) 9 M%*"#*%& +!% e;!l,!'* $e!",h!% "e#h!+! 25 O$"/e# 2015 @ SPO el!#!% h!'*l $#*"*' 15 Ne/e# 2015 S,#!" e/e#*"!h,!% #e'* +!#* D*#e$",# 26 O$" /e# 2015 $e!+! l!/#!"#*, #,,$!% l,!# /e#$!*"!% +e%&!% '"!%+!# 8!$", ee#*$'!!% $#*"*' 5 Me/,!" SPO #,,$!% ee#*$'!!% $#*"*' $e 26 O$"/e# 2015 l!/#!"#*, l,!# 1 Pe%!/!h!% ,l!h #*%" ," /!#3+e e# 15 Ne/e# 2015 !'*e% (20 l!/el /!#3+e 8!$", !',$ #!%!. 10 l!/l /!#3+e !',$ #!8!" !l!%) 2 M%*"#*%& +!% e;!l,!'* $e!",h!% SPO 15 Ne/e# 2015 *+e%"**$!'* 9 E;!l,!'* ,#!*!% ",&!' $#+*%!"# 'h*". 15 Ne/e# 2015 !',$$!% ',e#;*'* #'e' el!-!%!% Pe%!"!!% ,l!%&e#!*$!% !#e! $e#! ,%*" 15 Ne/e# 2015 )el!-!%!% +!% K!!%-e /,+!-! 5R (R*%&$!'.R!*.Re'*$.R!8!". R!*%)
PIC S; L!/#!"#*, K#'h*" K!I%' L!/#!"#*, < K!I%' IGD < M!%!e# ?!%&Me+*$ S; L!/#!"#*, < < <
S; L!/ #!"#*,
< S; L!/#!"#*, < M!% ?!%& Me+ < M!% RM < EDP < Pe%&!+!!% T* KPRS M!% SDI < <
S; Se,! ,%*" $e#! T* PPI
NO FM PRIORITAS 9 S,/e# +!-! l*'"#*$ "*+ !$ e!+!*
RANCANGAN ULANGPERBAIKAN 1 Me% -,',% ee"!!% , "*l*'!'* l *'"#*$ + !% $e/,",h!% 2 Me%-,',% $e/,",h!% 3!", +!-! 3!+!%&!% 9 Me%e"!$!% Se'**$!'* +!% $e/,",h!% UPS "*! !l!" +!% ,%*" e%"*%&
TARGET AKTU 15 Ne/e# 2015
PIC M!% ?!% & N %Me+
15 Ne/e# 2015 15 Ne/e# 2015
M!%?!%& N% Me+ < M!%?!%& N% Me+ < S; Ele$"#e+*$ < Se$#e"!#*!" D*#e$",# < S; EDP < S; Ele$"#e+*$
Me%e"!$!% ",&!' +!% $e8e%!%&!% 15 Ne/e# 2015 eel*h!#!!% UPS. el!l,* %"! +*%!': ! UPS ele$!" !+! !l!" e+*$ ele$"#e+*$ / UPS ele$!" !+! $,"e# EDP 5 Me%&,#!%&* !$"# #*'*$ o.er%eatin/ 15 Ne/e# 2015 #,!%&!% l!/#!"#*,: ! Me%,", $!3! /!&*!% /!#!" ('ee#"* 15 Ne/e# 2015 #,!%& #el!'*BP?S) / Peel*h!#!!% AC /e#$!l! 15 Ne/e# 2015 = Me%&,#!%&* !$"# #*'*$ o.er%eatin/ !#e! 15 Ne/e# 2015 &e%'e"
M!%?!%& N% Me+ S; Peel*h!#!!% S; Peel*h!#!!%
I
LANGKAH 6 : U?ICOBA DESAIN ULANG G!/!# D*!&#! Se"el!h De'!*% Ul!%& ! D*!&#! Al,# Pe#!l!"!% Me%*l!* Kel!-!$!%$e/,",h!% !l!" l!/#!"#*,
Pe(/el*!%)e%&!+!!%
Peel*h!#!!%
Pe%,%,$!% "* )e(/el*!% Me%e"!)$!% ')e'**$!'*
Pe#/!*$!%
K!l*/#!'*
Ce$ !+8!l )e(el*h!#!!%
L!)#!% $e#,'!$!%
Ce$ !'!
Ke#!'!(! ,%*" ele$"#e+*$
Ke#!'!(! ,%*" ele$"#(e+*$
1 Se'**$!'* !l!" 2 Ke/,",h!% +!-! l*'"#*$. !#,'. /roundin/ Pe%,%,$$!% #+,$ +!% ',l*e# P#'e' e/el*!%
Pe#/!*$!% leh ele$"#e+*$ ',l*e#
E;!l,!'* +!% ,*3/!
/e#l!$, $!l*/#!'* 9 /,l!% 'e/el, /e#!$h*#. e%&!,$!% e#h%!% $!l*/#!'* $e BPFK S,#!/!-!
Me%,%&&, $%*#!'* !+8!l $!l*/#!'*
P#'e' $!l*/#!'* 'e#"**$!" $!l*/#!'*
/ D*!&#! Al,# Pel!-!%!% L!/#!"#*, * R!8!" ?!l!% PASIEN
PENDAFTARAN (TPPR?)
PERIKSA DOKTER IDENTIFIKASI SURAT PERMINTAAN PEMERIKSAAN IDENTIFIKASI ENTRY DATA PELAYANAN LABORATORIUM IDENTIFIKASI SAMPLING DAN PEMBERIAN LABEL PASIEN PADA TABUNG SPESIMEN
PREPARASI
1 IDENTIFIKASI
2 PENILAIAN KUALITAS SPESIMEN
PROSES ANALISIS
KOREKSI HASIL IDENTIFIKASI ALIDASI DAN INTERPRETASI
ALIDASI DAN INTERPRETASI
PEMERIKSAAN HASIL KRITIS
PEMERIKSAAN HASIL TIDAK
LAPOR DOKTER PATOLOGI
HUBUNGI IGDPOLIKLINIK
CETAK HASIL IDENTIFIKASI HASIL DISERAHKAN PASIEN
** R!8!" I%! ASESMEN MEDIS IDENTIFIKASI SURAT PERMINTAAN PEMERIKSAAN IDENTIFIKASI SAMPLING DAN PEMBERIAN LABEL PASIEN PADA TABUNG SPESIMEN IDENTIFIKASI ENTRY DATA PELAYANAN LABORATORIUM
1
IDENTIFIKASI
2 PENILAIAN KUALITAS SPESIMEN
PREPARASI
PROSES ANALISIS
KOREKSI HASIL IDENTIFIKASI ALIDASI DAN INTERPRETASI
PEMERIKSAAN HASIL KRITIS
PEMERIKSAAN HASIL TIDAK
LAPOR DOKTER PATOLOGI KLINIK LAPOR PERAAT RUANG
CETAK HASIL IDENTIFIKASI HASIL DISERAHKAN
LANGKAH > : IMPLEMENTASI DAN MONITORING DESAINRANCANGAN BARU M%*"#*%& RPN P!'3! Ilee%"!*' De'!*% Ul!%& Pel!-!%!% L!/#!"#*, Failure Mode P#*#*"!' Pee#*$'!!% +!% h!'*l $#*"*' "*+!$ "e#l!/!" +*l!#$!%
1
2
9
5
Ke'!l!h!% e%eel!% l!/el *+e%"*"!' !'*e% !+! ',#!" e#*%"!!%
1
2 9
RPN Se/el, Pe#/!*$!% De'!*% Ul!%& Me%*%&$!"$!% $e+*'*l*%!% 1=2 e%&*'*!% /,$, $h,',' l!#!% h!'*l $#*"*' E+,$!'* e",&!' l!/#!"#*, (TLM) e%"*%&%-! 'e&e#! el!#$!% h!'*l $#*"*' (e#"e,!% e/,!"!% '"e#) M%*"#*%& +!% e;!l,!'* $e!",h!% "e#h!+! SPO el!#!% h!'*l $#*"*' S,#!" e/e#*"!h,!% #e'* +!#* D*#e$",# $e)!+! l!/#!"#*, #,,$!% l,!# /e#$!*"!% +e%&!% '"!%+!# 8!$", ee#*$'!!% $#*"*' Me/,!" SPO #,,$!% ee#*$'!!% $#*"*' $e l!/#!"#*, l,!# Pe%!/!h!% ,l!h #*%" ," 12> /!#3+e e# !'*e% (20 l!/el /!#3+e 8!$", !',$ #!%!. 10 l!/el /!#3+e !',$ #!8!" !l!%) M%*"#*%& +!% e;!l,!'* $e!",h!% SPO *+e%"**$!'* E;!l,!'* ,#!*!% ",&!' $#+*%!"# 'h*". (!',$$!% ',e#;*'* #'e' el!-!%!% Pe%!"!!% ,l!%&e#!*$!% !#e! $e#! ,%*" )el!-!%!% +!% K!!%-e /,+!-! 5R (R*%&$!'.R!*.Re'*$.R!8!". R!*%)
RPN Se"el!h De'!*% Ul!%& 195
=
Failure Mode P#*#*"!' S,(/e# +!-! l*'"#*$ "*+!$ e!+!*
Pe#/!*$!% 1 Me%-,',% ee"!!% ,"*l*'!'* l*'"#*$ +!% $e/,",h!% 2 Me%-,',% $e/,",h!% 3!", +!-! 3!+!%&!% 9 Me%e"!$!% S)e'**$!'* +!% $e/,",h!% UPS "*! !l!" +!% ,%*" e%"*%& Me%e"!$!% ",&!' +!% $e8e%!%&!% eel*h!#!!% UPS 5 Me%&,#!%&* !$"# #*'*$ #,!%&!% o.er%eatin/ l!/#!"#*, = Me%&,#!%&* !$"# #*'*$ o.er%eatin/ !#e! &e%'e"
RPN Se/el, De'!*% Ul!%& 120
RPN Se"el!h De'!*% Ul!%& 100
