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Analisis penghalang
BARRIER ANALYSIS
Hazard, Barrier, Target Analysis
Barrier
Dog Child
Hazard Target
HighFence
BARRIER
• Barrier: penghalang agar adverse event tidak terjadi
• Instrumen untuk mengidentifikasi barier keselamatan untuk mencegah kejadian yg tak diharapkan
2
• Penghalang atau kontrol untuk mencegah terjadinya bahaya• Analisa penghalang didesain untuk mengidentifikasi :
1. Penghalang mana yang seharusnya untuk mencegah insiden2. Mengapa penghalang gagal ?3. Penghalang apa yang dapat digunakan untuk mencegah insiden
terulang kembali ?
Ada 4 tipe penghalang:1. Penghalang Fisik2. Penghalang Natural3. Penghalang Tindakan manusia4. Penghalang Administrasi
ANALISIS PENGHALANG/ACCIDENT
BARRIER
Makin keatas (mendekati accident), barrier semakin kecil
KAPAN DIGUNAKAN BARRIER ANALYSIS
• STAND ALONE• SETELAH DILAKUKAN INVESTIGASI
RCA
• SKALA EFEKTIFITAS (1 – 6)– Skala 1: paling efektif– Skala 6: paling tidak efektif
IDENTIFIKASIKAN BARRIER YANG MUNGKIN DIPASANG
Barrier
Dog Child
Hazard Target
1.…2.…3.…
3
APA YANG HARUS DILAKUKAN AGAR ANAK TIDAK DIGIGIT ANJING
No. BARRIER RATING (1-6)12
Hazard: Anjing GalakTarget: Anak KEcil
4
5
BarrierHazard Target
Melindungi target dari hazard
PasienSumber potensial menyebabkan harm
/ kerugian
ANALISIS PENGHALANG / BARRIER ANALYSIS APA YANG HARUS DILAKUKAN AGAR
TIDAK SALAH SISI OPERASI
No. BARRIER RATING (1-6)12
Hazard: Operasi pada sisi yang salahTarget: Pasien
6
Problem: tourniquet applied to incorrect leg by consultant surgeon and assistantWhatbarriers/controls/defenceswere in place?
Did thebarrier/control/defencework?
Why did the barrier/control/defence fail and whatwas its impact?
Guideline states that the surgeon or assistant should see and check all patients including the operation site mark prior to the procedure.
No 1. Guideline did not state when and whom should do this. Task was partially completed by assistant and consultant, but communication and information transfer was incomplete.2. Consultant prefers to see his patients pre-operatively the day before procedure and mark the operative site himself. However, due to late admission the operative site was marked by an untrained SHO.
Correct and appropriate marking of operative site.
No 1. SHO applied mark via a skin pencil in an unusual site, which would not be immediately 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.
Barrier Analysis(Wrong Site Surgery Case) TUGAS ( 15 menit)
KASUS 1: Insiden Angiografi
Berdasarkan:• Laporan kejadian RS. Sejahtera Medika • Rekam medis Kasus Tuan Budi.S
• Tiap Kelompok bertugas:1. Menetapkan Hazard2. Menetapkan Barier yang mungkin3. Menentukan skala efektifitas untuk setiap
barier
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