WORKSHEET FMEA

LANGKAH 1
JUDUL PROSES BERISIKO TINGGI
TANGGAL DIMULAI
TANGGAL SELESAI

PEMBENTUKAN TIM
KETUA
ANGGOTA

FASILITATOR
NOTULEN

SASARAN / GOAL

Project Status
Status COMPLETE
TOTAL FAILURE MODE : ……….

LANGKAH 2
 ALUR PROSES

PROSES
1 2 3 4 5

SUB PROSES

a a

b b

c c

f
6 8 9
LANGKAH 3,

MODUS KEGAGALAN DAN DAMPAK

Sub Proses: 1. ………………………….. ; Tim leader : ………………….. ; Date : ……………..

Likelihood
Detection
Potential Failure Mode Potential Effects of Potential Cause of

RPN
Severity
Failure Effect
Current Controls

slh pemberian obat pasien cedera BLM ADA SPO 4 3 2 24

4 2 2 16
3 2 1 6
3 3 2 18
4 5 2 40
3 4 2 24
0
0
0
0
0
0
0
0
0
Sub Proses . ………………………….. ; Tim leader : ………………….. ; Date : ……………..

Likelihood
Detection
Potential Failure Mode Potential Effects of Potential Cause of Current Controls

RPN
Severity
Failure Effect

3 2 4 24
4 2 2 16
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Sub Proses. ………………………….. ; Tim leader : ………………….. ; Date : ……………..

 Likelihood
Detection
Potential Failure Mode Potential Effects of Potential Cause of Current Controls

RPN
Severity
Failure Effect

3 2 4 24
 4 2 2 16
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Sub Proses. ………………………….. ; Tim leader : ………………….. ; Date : ……………..

 Likelihood
Detection
Potential Failure Mode Potential Effects of Potential Cause of Current Controls

RPN
Severity
Failure Effect

3 2 4 24
4 2 2 16
0
0
0
0
0
0
0
0
0
0
0
0
0
0

Sub PRoses1. ………………………….. ; Tim leader : ………………….. ; Date : ……………..

 Likelihood
Detection
Potential Failure Mode Potential Effects of Potential Cause of Current Controls

RPN
Severity
Failure Effect

3 2 4 24
4 2 2 16
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Potential Failure Mode Potential Potential Cause Current Controls

Severity

Likelihood
Effects for of Effect
Failure

pasien cedera BLM ADA SPO 4 3 2

4 2 2
3 2 1
3 3 2
4 5 2
3 4 2
4 2
Detection

RPN

24 144
16 64
6 12
18 108
40 400
24 192
2 16
 Policy / Kebijakan
People / Man Metode

Cause Cause

Cause Cause

Cause
Cause
Cause

Caus Cause Caus

e e

Cause

Machine / alat Material / suplies

 Effect / Dampak
(Y)

aterial / suplies
 REDESAIN PROCESS

No
Critical / Prioritas Modus Kegagalan Root Cause Rekomendasi
Jangka Pendek / Jangka
Panjang
 Critical / Prioritas Modus Reassessment
No Root Cause Rekomendasi
Kegagalan Date
Likelihoo Detectibilit
Severity New RPN
d y