1

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