Keselamatan pasien - KMPK

21 steps of RCA (Joint commission)Steps Descriptions Note and Tools1 Organize a teamSize fewer than 102 Define the problem Brainstorming, multivoting, FMEA3 Study the problem Braintorm, flowchart, pareto, scatter, affinitydiagram, etc4 Determine what happen Flow chart, timeline5 Identify contributing factors Control chart, tree analysis, FMEA6 Identify other contributing factors Brainstorm, affinity diag, cause-effect diagram7 Measure, collect and assess data on proximate and underlyingcauses8 Design and implement interim changes Gantt chartSee how to develop indicators9 Identify which systems are involved (the root causes) Flow chart, cause effect diag, fmea, treeanalysis, barrier analysis10 Prune the list of root causes11 Confirm root causes12 Explore & identify risk-reduction strategies FMEA13 Formulate improvement actions Brainstorm, flow chart, cause effect diagram14 Evaluate Proposes Improvement Actions15 Design improvements Gantt chart16 Ensure acceptability of the action plan17 Implement the Improvement Plan PDCA, critical path18 Develop measures of effectiveness and ensure their success19 Evaluate implementation of improvement plan Run chart, control chart, histogram20 Take additional action21 Communicate the results28