10.langkah Ke 7-Cegah Cedera Melalui Implementasi Keselamatan Pasien (DR - Arjaty)

LANGKAH 7
Dr Arjaty W Daud MARS
1.
2. 3. 4.
LATAR BELAKANG PERLUNYA REDESAIN PROSES DI PELAYANAN KESEHATAN STRATEGI REDUKSI RISIKO IDENTIFIKASI PROSES YG RISIKO TINGGI REDISAIN PROSES : - FMEA - AMKD / HFMEA
Arjaty/ IMRK/FMEA/2008
Historical Perspective
Hingga saat ini, pencegahan kesalahan Until recently, error prevention has not medisabelum menjadi of medicine bidang been primary focus fokus utama kedokteran System/process defects are identified by adverse events or dealt with silently by health care personnel Sebagian besar sistem pelayanan Most health caredidesain untuk mencegah kesehatan tidak delivery systems are not designed to prevent and / or error atau mencegah / mengatasi compensate for errors
Arjaty/ IMRK/FMEA/2008 3
JCAHO Standard LD 5.2

(efective July 2001)
Identify anddan proritaskan PROSES Identifikasi prioritize high risk processes Annually select at TINGGI YANG BERISIKO least one high risk process Identifikasi POTENSI MODUS Identify potential KEGAGALAN failure modes For each failure mode, identify possible Setiap modus kegagalan, IDENTIFIKASI effects DAMPAK YANG MUNGKIN TERJADI For the most dampak yang kritis, Untuk setiap critical effects, conduct a root cause analysis LAKUKAN ANALISIS AKAR MASALAH.
JCAHO Standard LD 5.2

(efective July 2001)
REDISAIN PROSES untuk Redesign the process to minimize the risk of that failure mode or to protect patients from its meminimalisasi risiko modus kegagalan effectsmencegah dampaknya pada pasien atau Test and implement IMPLEMENTASI the redesigned process UJI COBA DAN Identify and implement measures of REDISAIN PROSES effectiveness IDENTIFIKASI DAN NILAI EFEKTIVITAS Implement a strategy for maintaining the IMPLEMENTASI effectiveness of the redesigned process over timeatau proses redisain. STRATEGI untuk IMPLEMENTASIKAN efektivitas maintanance
6
Advanced Patient safety in US since 1999, NPCS, August 2004, www,patientsafety.gov
RISK REDUCTION STRATEGIES DIFFICULTY & LONG TERM EFFECTIVENESS Types of actions Degree of difficulty Easy
1. 2.
Long term effectiveness Low
Punitive Retraining / counseling
3.
4. 5. 6.
Process redesign
Paper vs practice Technical system enhance Culture change Difficult
High
7
Definition of a Process
A goal-directed interrelated series of events, activities, actions, mechanisms, or steps that transform inputs into outputs
(CAMH Glossary)
INPUT
PROSES
OUTPUT
STRATEGI REDUKSI RISIKO Identifikasi risiko dgn bertanya 3 pertanyaan dasar : 1. Apa prosesnya ? 2. Dimana risk points / cause? 3. Apa yg dapat dimitigate pada dampak risk points ?
STRATEGI REDUKSI RISIKO

RISK POINTS / COMMON CAUSES
RENCANA REDUKSI RISIKO
Design Proses u/ Meminimalkan risiko kegagalan
Design Proses u/ Meminimalkan risiko Kegagalan terjadi Arjaty/ IMRK/FMEA/2008 Pada pasien
Design Proses u/ Mengurangi Dampak Kegagalan terjadi 10 pada pasien
MEMILIH PROSES
High Risk processes
Identified in the literature Identified by JCAHO Identified through safety alerts
New or redefined process Staff recommendations
11
IDENTIFYING RISK PRONE SYSTEM Variable input Complex systems Non standardized systems Tightly coupled systems Systems with tight time constraints Systems with hierarchical
12
REDISAIN PROSES
FMEA
Variable input Complex Nonstandarized Tightly Coupled Dependent on human intervention Time constraints Hierarchical culture
Decreasing variability Simplify Standardizing Loosen coupling of process Use technology Optimise Redundancy Built in fail safe mechanism Documentation Establishing a culture of teamwork
13
Variable input
Pasien Penyakit berat Penyakit penyerta Pernah mendapatkan pengobatan Usia Pemberi Pelayanan Tingkat keterampilan Cara pendekatan Proses Pelayanan harus dapat mengakomodasi variabilitas yang tdk dapat dihindarkan dan tidak dapat dikontrol ini.
Complexitas
Pelayanan rumah sakit sangat kompleks Memerlukan beragam langkah yang sangat mungkin berhadapan dengan kegagalan Semakin banyak langkah semakin besar kemungkinan gagal Donald Berwick : 1 langkah -- error 1 % 25 langkah -- error 22% 100 langkah -- error 63%
Lack of Standardization
proses tidak dapat berjalan sesuai dengan harapan Individu yang menjalankan proses harus melaksanakan langkah langkah yang telah ditetapkan secara konsisten Variabilitas individual sangat tinggi perlu standard mis : SPO, Parameter, Protokol, Clinical Pathways dapat membatasi pengaruh dari variabel yang ada.
Standard - --
Heavily dependent on human Intervention Ketergantungan yang tinggi akan intervensi seseorang dalam proses dapat menimbulkan variasi penyimpangan. Tidak semua improvisasi bersifat buruk, dikenal creating safety at the sharp end Pelayanan kesehatan sangat tergantung pada intervensi manusia Petugas harus mampu mengendalikan situasi yang tidak terduga demi keselamatan pasien Sangat tergantung pada pendidikan dan pelatihan yang memadai sesuai dengan tugas & fungsinya
Tightly Coupled
Perpindahan langkah dari suatu proses sering sangat ketat, kadang baru disadari terjadi penyimpangan pada langkah yang telah lanjut. Keterlambatan dalam suatu langkah akan mengakibatkan gangguan pada seluruh proses Kekeliruan dalam suatu langkah akan mengakibatkan penyimpangan pada langkah berikut ( cascade of faillure ) Kesalahan biasanya terjadi pada saat perpindahan langkah atau adanya langkah yang terabaikan
Hierarchical culture
Suatu proses akan menghadapi risiko kegagalan lebih tinggi dalam unit kerja dengan budaya hirarki dibandingkan dengan unit kerja yang budayanya berorientasi pada team. Staf enggan berkomunikasi & berkolaborasi satu dengan yang lain Perawat enggan bertanya kepada dokter atau petugas farmasi tentang medikasi, dosis, serta element perawatan lainnya Budaya hirarki sering tercipta misalnya dalam menentukan penggunaan obat, verifikasi lokasi pembedahan oleh tim bedah. Tata cara berkomunikasi antar staf dalam proses Arjaty/ IMRK/FMEA/2008 pelayanan kesehatan sangat menentukan hasilnya.
19
Implementing Safety Cultures in Medicine: What We Learn by Watching Physicians

Timothy J. Hoff, Henry Pohl, Joel Bartfield
Residen di Kamar Bedah : ~ Commission ~ Suasana hierarki tinggi ~ Kesalahan Teknis Residen di MICU : ~ Ommission Suasana hierarki lebih datar ~ Kesalahan Pengambilan Keputusan
20
What is FMEA ?
Adalah metode perbaikan kinerja dgn mengidentifikasi dan mencegah potensi kegagalan sebelum terjadi. Hal tersebut didesain untuk meningkatkan keselamatan pasien. Adalah proses proaktif, dimana kesalahan dpt dicegah & diprediksi. Mengantisipasi kesalahan akan meminimalkan dampak buruk
21
FMEA Whats the point?

Eliminatingmengeliminasi atau mereduksi Dengan or reducing the risk of the failure modes can result in a risiko kegagalan akan menghasilkan suatu SAFER AND MORE EFFICIENT SYSTEM SISTEM YANG AMAN DAN LEBIH EFISIEN from which BAGI you and your patients benefit. both RS DAN PASIEN.
22
Failure Mode and Effects Analysis

1. Define failure mode.
what could go wrong?
2. Identify cause of failure. 3. Identify effects of failure

why would the failure happen? what would be the consequences of each failure?
4. Corrective action.
FMEA Terminology
Process FMEA - Conduct an FMEA on a process that is already in place Design FMEA Conduct an FMEA before a process is put into place
Implementing an electronic medical records or other automated systems Purchasing new equipment Redesigning Emergency Room, Operating Room, Floor, etc.
FAILURE MODE AND EFFECTS ANALYSIS

FAILURE (F) : When a system or part of a system performs in a way that is not intended or desirable MODE (M) : The way or manner in which something such as a failure can happen. Failure mode is the manner in which something can fail. EFFECTS (E) : The results or consequences of a failure mode Analysis (A) : The detailed examination of the elements or structure of a process
Why should my organization conduct an FMEA ?

Can prevent errors & near misses protecting patients from harm. Can increase the effectiveness & efficiency of process Taking a proactive approach to patient safety also makes good business sense in a health care environment that is increasingly facing demands from consumers, regulators & payers to create culture focused on reducing risk & increasing accountability
Where did FMEA come from ?

FMEA has been around for over 30 years Recently gained widespread appeal outside of safety area New to healthcare
Frequently used reliability & system safety analysis techniques Long industry track record : Aviation,
Nuclear power, Aerospace, Chemical process industries, Automoive

LANGKAH FMEA
1. 2. 3.
4. 5. 6. 7. 8.
Select a high risk process & assemble a team Diagram the process Brainstorm potential failure modes & determine their effects (P X S X D) Prioritize failure modes Identify root causes of failure modes (P X S X D) REDESIGN THE PROCESS Analyze & test the new process Implement & monitor the redesigned process
28
Step One
Select a process to evaluate with FMEA Recruit a multi disciplinary team
Be sure to include everyone who is involved at any point in the process
Step Two
Have the team meet together to list all the steps in the process Number every step in the process and be as specific as possible
Step Three
Have the team list failure modes and effect List anything that could go wrong including minor and rare problems Identify all possible causes for each failure mode
For each failure mode, determine the potential effect on the patient Likelihood of occurrence Likelihood of detection Severity
30
31
RATING SYSTEM (Modified by IMRK) Rating

1 2
Probabilitas (P)
Remote Low likelihood
Severity (S)
Minor effect Moderate effect
Deteksi (D)
Certain to detect High likelihood
3 4 5
Moderate likelihood High likelihood Certain to occur
Minor injury Major injury Catastrophic effect / terminal injury, death
Moderate likelihood Low likelihood Almost certain not to detect
Risk Priority Number (RPN) / Criticaly Index (CI) = (P x S) x D

Step four
Prioritize failure mode
Step five
Have the team list effect of failure mode
For each failure mode, determine the potential cause on the patient Likelihood of occurrence Likelihood of detection Severity
Step Six
REDESIGN PROCESS Determine which failures to work on Calculate the RISK PRIORITY NUMBER (RPN): Likelihood x Severity x Detection Identify the failure modes with the top 10 RPNs
TAKE A DEEP BREATH Conduct a literature search to gather relevant information from the professional literature. Do not reinvent the wheel Network with colleagues RECOMMIT TO OUT OF THE BOX THINKING
Step Seven
Analyze and test the new process Use RPNs to plan improvement efforts Failure modes with high RPNs are usually the most important parts of the process to concentrate improvement efforts. The team again completes steps 2 (diagram the process), step 3 (brainstorm potential failure modes & determine their effect) and step 4 (prioritize failure modes) of the FMEA process Then the team should calculate a new criticality index (CI) or RPN.
Step Eight
Implement & monitor the redesigned process Design improvements should bring reduction in the CI / RPN. Ex: 30 50% reduction ?
36
What is HFMEA ?
Modified by VA NCPS Focus on preventing defects, enhancing safety, increase positive outcome and increase patient satisfaction The objective is to look for all ways for process or product can fail The famous question : What is could happen? Not What does happen ? Hybrid prospective analysis model combines concepts :
FMEA (Failure Mode and Effects Analysis) HACCP (Hazard Analysis Critical Control Points) RCA (Root Cause Analysis)
HFMEA Components and Their Origins

Concepts
Team membership Diagramming process Failure mode & causes Hazard Scoring Matrix Severity & Probability Definitions Decision Tree Actions & Outcomes Responsible person & management concurrence
HFMEA
V V V V V V V V
FMEA
V V V
HACCP
RCA
V
V # V # #
V V
38
HACCP : Hazard Analysis Critical Control Point
TIME LINE AND TEAM ACTIVITIES

Premeeting 1st team meeting 2rd team meeting 3 rd team meeting 4rd team meeting 5th team meeting Identify Topic and notivy the team (Step 1 & 2) Diagram the process, identify subprocess, verify the scope Visit the worksite to observe the process, verify that all process & subprocess steps are correct (Step 3) Brainstorming failure modes, assign individual team members to consult with process users (Step 3) Identify failure modes causes, assign individual team members to consult with process users for additional input (Step 3) Transfer FM & Causes to the HFMEA Worksheet (Step3). Begin the hazard analysis (Step 4) Identify corrective actios and assign follow up responsibilities (Step 5) Assign team members to follow up individual charged with taking corrective action Refine corrective actions based on feedback Test the proposed changes Meet with Top Management to obtain approval for all actions The advisor or his/ her designee follow up until all actions are completed
6th,7th , 8th. team meeting plus 1 team meeting plus 2 team meeting plus 3 team meeting plus 4 Postteam meeting
LANGKAH-LANGKAH ANALISIS MODUS KEGAGALAN & DAMPAK (AMKD) (HEALTHCARE FAILURE MODE EFFECT AND ANALYSIS) (HFMEA) By : VA NCPS
1. Tetapkan Topik AMKD

2. Bentuk Tim 3. Gambarkan Alur Proses 4. Buat Hazard Analysis 5. Tindakan dan Pengukuran Outcome
Step 1
Define the Scope of HFMEA along with a clear definition of the process to be studied
Step 2
Multidisiplinary team with Subject matter expert(s) plus advisor
Step 3
Develop and verify the flow Diagram (this is a process vs chronological diagram) Consecutively number each process step identified in the process flow diagram If the process is complex identify the area of the process to focus on (manageable bite) Identify all sub processes under each block of this flow diagram. Consecutively letter these sub steps Create a flow diagram composed of the sub processes
Step 4
List Failure modes Determine Severity & Probability Use the Decision tree List all Failure mode causes
43
Step 5
Decide to Eliminate Control or Accept the failure mode cause Describe an action for each failure mode cause that will eliminate or control it. Identify outcome measures that will be used to analyze and test the re-designed process Identify a single, responsible individual by title to complete the recommended action Indicate whether top management has concurred with the recommended actions
FMEA vs HFMEA vs HFMECA

FMEA Original 1 2 3 Select a high risk process & assemble a team Diagram the process Brainstorm potential failure modes & determine their effects (P X S X D) Prioritize failure modes Identify root causes of failure modes (P X S X D) REDESIGN THE PROCESS Analyze & test the new process Implement & monitor the redesigned process
HFMEA By : VA NCPS Define the HFMEA Topic Assemble the Team Graphically describe the Process Conduct a Hazard Analysis Actions & Outcome Measures
HFMECA By IMRK Select a high risk process & assemble a team Diagram the process Brainstorm potential failure modes (P X S) x K X D, Bands Prioritize failure modes Identify root causes of failure modes (P X S) x K X D, Bands CALCULATE TOTAL RPN REDESIGN THE PROCESS Analyze & test the new process Implement & monitor the redesigned process
45
4 5
6 7 8 9
RATING SYSTEM HFMECA (Modified by IMRK) Rating

1 2
Probabilitas (P)
Remote Low likelihood
Severity (S)
Minor effect Moderate effect
Kontrol (K)
Easy Mpderate Easy Moderate difficult Difficult
Deteksi (D)
Certain to detect High likelihood
3 4 5
Moderate likelihood High likelihood Certain to occur
Minor injury Major injury Catastrophic effect / terminal injury, death
Moderate likelihood Low likelihood Almost certain not to detect
Risk Priority Number (RPN) / Criticaly Index (CI) = (P x S) x K x D

47
LANGKAH 1 : PILIH PROSES YANG BERISIKO TINGGI Pilih Proses berisiko tinggi yang akan dianalisa. Judul Proses : __________________________________________________________________________
_________________________________________________________ _________________________________________________________
LANGKAH 2 : 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 ___________________
48
Contoh kasus 1
49
50
51
52
53
ANALISIS
DAMPA K MINOR 1 Kegagalan yang tidak mengganggu Proses pelayanan kepada Pasien Pasien Tidak ada cedera, Tidak ada perpanjangan hari rawat
HAZARD LEVEL DAMPAK

MODERAT 2 MAYOR 3 Kegagalan menyebabkan kerugian berat KATASTROPIK 4 Kegagalan menyebabkan kerugian besar
Kegagalan dapat mempengaruhi proses dan menimbulkan kerugian ringan Cedera ringan Ada Perpanjangan hari rawat
Cedera luas / berat Perpanjangan hari rawat lebih lama (+> 1 bln) Berkurangnya fungsi permanen organ tubuh (sensorik / motorik / psikcologik / intelektual) Cedera luas / berat Perlu dirawat Terjadi pada 4 -6 orang pengunjung Cedera luas / berat Perlu dirawat Kehilangan waktu / kecelakaan kerja pada 4-6 staf
Kematian Kehilangan fungsi tubuh secara permanent (sensorik, motorik, psikologik atau intelektual) mis : Operasi pada bagian atau pada pasien yang salah, Tertukarnya bayi Kematian Terjadi pada > 6 orang pengunjung
Pengunju ng
Tidak ada cedera Tidak ada penanganan Terjadi pada 1-2 org pengunjung Tidak ada cedera Tidak ada penanganan Terjadi pada 1-2 staf Tidak ada kerugian waktu / keckerja Kerugian < 1 000,,000 atau tanpa menimbulkan dampak terhadap pasien
Cedera ringan Ada Penanganan ringan Terjadi pada 2 -4 pengunjung Cedera ringan Ada Penanganan / Tindakan Kehilangan waktu / kec kerja : 2-4 staf
Staf:
Kematian Perawatan > 6 staf
Fasilitas Kes
Kerugian Kerugian 10,000,000 - 50,000,000 1,000,000 - Arjaty/ IMRK/FMEA/2008 10,000,000
Kerugian > 50,000,000

54
ANALISIS HAZARD LEVEL PROBABILITAS

LEVEL 4 DESKRIPSI Sering (Frequent) CONTOH Hampir sering muncul dalam waktu yang relative singkat (mungkin terjadi beberapa kali dalam 1 tahun) Kemungkinan akan muncul (dapat terjadi bebearapa kali dalam 1 sampai 2 tahun) Kemungkinan akan muncul (dapat terjadi dalam >2 sampai 5 tahun)
Kadang-kadang (Occasional) Jarang (Uncommon)
2 1
Hampir Tidak Pernah Jarang sekali terjadi (dapat terjadi dalam (Remote) > 5 sampai 30 tahun)
HAZARD SCORE
TINGKAT BAHAYA KATASTROPIK 4 SERING 4 KADANG 3 JARANG 2 HAMPIR TIDAK PERNAH 1 MAYOR MODERAT 3 2 MINOR 1
16 12 8 4
12 9 6 3
8 6 4 2
4 3 2 1
56
Decision Tree
Gunakan Decision Tree utk menentukan apakah modus perlu tindakan lanjut diProceed..
Does this hazard involve a sufficient likelihood of occurrence and severity to warrant that it be controlled? (Hazard score of 8 or higher) YES NO
Is this a single point weakness in the process? (Criticality failure results in a system failure?) CRITICALY YES Does an effective control measure already exist for the identified hazard? CONTROL NO Is this hazard so obvious and readily apparent that a control measure is not warranted? DETECTABILITY NO
NO
YES
STOP
Do not proceed to find potential causes for this failure mode
YES
Proceed to Potential Causes for this failure
57
Contoh kasus 2
PROSES KEGIATAN PAGI HARI MENUJU TEMPAT KERJA
58
59
60
61
62
63
64
65
LEMBAR AMKD ( FORM HFMEA )

AMKD Langkah 4 - Analisis Hazard
MODUS Kegagalan : Evaluasi awal modus kegagalan sebelum SKORING Analisis Pohon Keputusan Tipe Tindakan (Kontrol, Kontrol, terima, terima, Eliminasi) Eliminasi) Tindakan / Alasan untuk mengakhiri AMKD Langkah 5 - Identifikasi Tindakan & Outcome Yang Bertanggung Jawab Ukuran Outcome Ukuran Outcome Manajemen Tim
Apakah ada Apakah ada kontrol/pengen kontrol/pengen dalian?
Apakah mudah didteksi ? didteksi ?
Poin Tunggal Poin Tunggal Kelemahan ? Kelemahan ?
Probabilitas Probabilitas
Nilai Hazard
Kegawatan
POTENSI PENYEBAB
Turn off alarm
major
occas ional
Proses ? Proses ?
Missed snooze button
major
Occa sional
Eliminate
Purchased new clock
Purc hase d by cert ain date .....
Mr..
Yes
Arjaty/ IMRK/FMEA/2008 HFMEA : Healthcare Failure Mode Effect and Analysis
66
AMKD / HFMEA
Proses lama yg high risk Alur Proses Potential Cause Failure Mode Efek / Dampak HS Decision Tree K K D T Desain Proses baru Hazard Score
Kritis Kontrol Deteksi Kontrol Eliminasi Terima
Tindakan K E
67
AMKDP / HFMECA
Total RPN PROSES LAMA Failure Mode, Dampak, Penyebab Total RPN 30-50%? Analisis & Uji Proses Baru Total RPN PROSES BARU Failure Mode, Dampak, Penyebab
Prioritas risiko
Redisign Proses
Implementasi PROSES BARU
68
KESIMPULAN
Building a safe healthcare system
A R L E T N E T P A U A O L R M R I E W T S I O I N R S G K
U
L E A R N I N G
S E V E R I T Y
L E A D E R S H I P
K F K D O R O E N T E T T R K M E R U A U O K N I L S E I N N I K I A S N I S G I
69
Team Work ?
70

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LANGKAH 7

Dr Arjaty W Daud MARS

JCAHO Standard LD 5.2

JCAHO Standard LD 5.2

Long term effectiveness Low

Punitive Retraining / counseling

STRATEGI REDUKSI RISIKO

RENCANA REDUKSI RISIKO

Design Proses u/ Meminimalkan risiko kegagalan

Design Proses u/ Mengurangi Dampak Kegagalan terjadi 10 pada pasien

New or redefined process Staff recommendations

Implementing Safety Cultures in Medicine: What We Learn by Watching Physicians

FMEA Whats the point?

Failure Mode and Effects Analysis

2. Identify cause of failure. 3. Identify effects of failure

FAILURE MODE AND EFFECTS ANALYSIS

Why should my organization conduct an FMEA ?

Where did FMEA come from ?

Nuclear power, Aerospace, Chemical process industries, Automoive

Be sure to include everyone who is involved at any point in the process

RATING SYSTEM (Modified by IMRK) Rating

Moderate likelihood High likelihood Certain to occur

Minor injury Major injury Catastrophic effect / terminal injury, death

Moderate likelihood Low likelihood Almost certain not to detect

Risk Priority Number (RPN) / Criticaly Index (CI) = (P x S) x D

HFMEA Components and Their Origins

HACCP : Hazard Analysis Critical Control Point

TIME LINE AND TEAM ACTIVITIES

1. Tetapkan Topik AMKD

FMEA vs HFMEA vs HFMECA

RATING SYSTEM HFMECA (Modified by IMRK) Rating

Moderate likelihood High likelihood Certain to occur

Minor injury Major injury Catastrophic effect / terminal injury, death

Moderate likelihood Low likelihood Almost certain not to detect

Risk Priority Number (RPN) / Criticaly Index (CI) = (P x S) x K x D

HAZARD LEVEL DAMPAK

Kematian Perawatan > 6 staf

Kerugian Kerugian 10,000,000 - 50,000,000 1,000,000 - Arjaty/ IMRK/FMEA/2008 10,000,000

Kerugian > 50,000,000

ANALISIS HAZARD LEVEL PROBABILITAS

Kadang-kadang (Occasional) Jarang (Uncommon)

Proceed to Potential Causes for this failure

LEMBAR AMKD ( FORM HFMEA )

Apakah ada Apakah ada kontrol/pengen kontrol/pengen dalian?

Apakah mudah didteksi ? didteksi ?

Poin Tunggal Poin Tunggal Kelemahan ? Kelemahan ?

Turn off alarm

Missed snooze button

Purchased new clock

Purc hase d by cert ain date .....

Arjaty/ IMRK/FMEA/2008 HFMEA : Healthcare Failure Mode Effect and Analysis

Implementasi PROSES BARU

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