7-risk analysis_b.pdf

7/27/2019 7-Risk analysis_b.pdf

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Risk analysis

Pengertian

The development of qualitative and / or quantitative

estimate of risk based on evaluation and mathematical

techniques. (FAA System Safety Handbook, Dec

2000)

The process by which hazards are identified and

analyzed for their likelihood of occurrence and their

potential severity. (GAIN, 2003., Guide to methods

and tools for safety analysis in air traffic

management)

Risk = the expected loss per unit time or activity

Lingkup risk analysis

Looks hazards to determine:

What can happen

When it could happen

Factors associated with their occurrence



Tools untuk risk analysis

Severity assessment -- selecting events for

investigation Root Cause Analysis

Failure mode and effect analysis

Adverse eventManagement process

Risk identification

Risk analysis

Risk evaluation

Risk treatment

Ongoing monitoring

Communication

Audits, complaints,

Claims and incidents

Severity analysis

RCA

Risk registersAction plan

Eliminate or minimizerisk

Review the effectivenessof investigations and

actors

Communicate risks andthe outcomes ofinvestigations

Sumber:Hunter area healthservice

Clinical GovernanceUnit (Agst, 2003)

Preventable harm

Identifying weaknessIn systems

Fixing weakness

In systems

Safety



Severity assessment

Selecting events for investigation

Severityassessment

1. Extreme risk2. High risk

3. Moderate risk4. Low risk

Probability

Severity

Frequent

ProbablePossible

UnlikelyRare

ExtremeMajor

ModerateMinor

Minimal

Root Cause Analysis



Steps for root cause analysis

Investigate events

Reconstruct events

Analyze causes

Develop action plans

Report RCA process and findings

Investigate events

Define the problem

Collect pertinent evidence

Conduct interview

Review event environment

Determine contributing factors

Establish a chain of events

Reconstruct events

Define events preceding the adverse event or

near miss

Determine actions and conditions leading up to

these events by developing a causal tree

Continue until you have identified underlying

systems causes or until it is unreasonable to go

further



Analyze causes

Identify root causes within your causal tree

Develop root cause statement

Develop action plans

Identify strategies that are appropriate to the

causes identified and acceptable to the

organization and to those who will be involve

in the changes

Develop a plan for addressing each root cause

and for measuring effectiveness of intervention

Gain agreement form organizational leadership

regarding actions to be taken

Record RCA process and

findings

Record the process and tools uses

The cost of the process

A summary of the events The investigation and analysis process

Findings



Understanding causes of events

Active failure: an intentional violation

committed by an individual Latent condition: a breakdown in process or

systems:

lack of education,

failure to follow procedure,

equipment defect,

poor design, etc

Philosophical viewpoints on human

errors

Human error is not the cause of events, it is a

symptom of deeper troubles in the system

Human error is not the conclusion of an

investigation, it is the beginning

Events are the result of multiple causes

21 steps of RCA (Joint commission)

Communicate the results21

Take additional action20

Run chart, controlchart, histogramEvaluate implementation of improvement plan19

Develop measures of effectiveness and ensure their success18

PDCA, criticalpathImplement the Improvement Plan17

Ensure acceptability of the action plan16

GanttchartDesign improvements15

Evaluate Proposes Improvement Actions14

Brainstorm, flow chart, causeeffect diagramFormulate improvement actions13

FMEAExplore & identify risk-reduction strategies12

Confirm root causes11

Prune the list of root causes10

Flow chart, cause effectdiag, fmea, treeanalysis,

barrier analysisIdentify which systems are involved (the root c auses)9

GanttchartDesign and implement interim changes8

Seeho w to develop indicatorsMeasure, collect and assess data on proximate and underlying causes7

Brainstorm, affinityd iag, cause-effectdiagramIdentify other contributing factors6

Controlch art, treeanalysis, FMEAIdentify contributing factors5

Flow chart, timelineDetermine what happen4

Braintorm, flowchart, pareto, scatter, affinity

diagram, etcStudy the problem3

Brainstorming, multivoting, FMEADefine the problem2

Sizefewer than 10Organize a team1

Note and ToolsDescriptionsSteps



Failure mode andeffect analysis

Apakah FMEA

Suatu alat mutu untuk mengkaji suatu prosedursecara rinci, dan mengenali model-modeladanya kegagalan/kesalahan pada suatuprosedur, melakukan penilaian terhadap tiapmodel kesalahan/kegagalan, dengan mencaripenyebab terjadinya, mengenali akibat darikegagalan/kesalahan, dan mencari solusidengan melakukan perubahan disain/prosedur

Langkah-langkah

Bentuk tim FMEA: orang-orang yang terlibatdalam suatu proses

Tetapkan tujuan, keterbatasan, dan jadual tim

Tetapkan peran dari tiap anggota tim

Gambarkan alur proses yang ada sekarang

Kenalilah Failure modes pada proses tersebut

Kenalilah penyebab terjadinya failure untuk tiapmodel kesalahan/kegagalan

Kenalilah apa akibat dari adanya failure untuktiap model kesalahan/kegagalan



Langkah-langkah….

Lakukan penilaian untuk tiap model kesalahan/kegagalan: Sering tidaknya terjadi (occurrence): (Occ)

0 : tidak pernah, 10 sangatsering Kegawatannya (severity): (SV)

0 : tidak gawat, 10 sangat gawat

Kemudahan untuk terdeteksi: (DT) 0 : mudah dideteksi, 10 : sangat sulitdideteksi

Hitung Risk Priority Number (RPN) dengan mengkalikan: Occ xSV x DT

Tentukan batasan (cut-off point) RPN yang termasuk prioritas

Tentukan kegiatan untuk mengatasi (design action/solution)

Tentukan cara memvalidasi apakah solusi tersebut berhasil

Gambarkan alur yang baru dengan adanya solusi tersebut

Design

Validati

on

Design

action/

Solution

RPNDTSVOCCEffects

of

failure

Cause of

failure

Failure

Mode

Occ : occurrence

SV : severityDT : detectableRPN: risk priority number

Diskusi

Pilih salah satu proses pelayanan klinis

yang bermasalah, yang mungkin

membahayakan pasien

Lakukan analisis dengan FMEA

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