JUDUL PROSES

TANGGAL DIMULAI
TANGGAL SELESAI
LATAR BELAKANG

LANGKAH 1
PEMBENTUKAN TIM
KETUA
ANGGOTA

FASILITATOR
NOTULEN

SASARAN / GOAL

Project Status
Status COMPLETE
TOTAL FAILURE MODE……….

ALUR PROSES
 PROSES
1 2 3 4 5

SUB PROSES

f
6 8 9
LANGKAH 3,4,5,6

MODUS KEGAGALAN DAN DAMPAK

Process/Product: 1.advis doktern; Tim leader : ………………….. ; Date : ……………..

Potential Failure Mode Potential Causes for Failure
LANGKAH 3,4,5,6

MODUS KEGAGALAN DAN DAMPAK

process/ product : 2. Penulisan resep

Potential Failure Mode Potential Causes for Failure
 Likelihoo
d
Detection

Likelihoo
d
Detection
Severity
Potential Effects of Current Controls

RPN
Recommended

New RPN
Severity
Failure Action

0
0
0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
0 0
 Failure
Potential Effects of
Current Controls

Severity
Likelihoo
d
Detection

RPN
Action
Recommended

Severity
Likelihoo
d
Detection

New RPN
Potential Failure Mode
Potential Causes of Failure Potential Effects of
Failure
 Current Controls

Severity

Likelihood
Detection

RPN
Recommended Action

Reassessmen
t Date
Likelihood
Severity

Detection

New RPN
 Action Plan :………………………
Failure Mode CAUSE Recommendation(s) Action(s) to
achieve
recommendati
ons (How)
Implementat Implemen Implementatio Resourc Resource Evidence of Monitoring Sign- Sign-
ion by tation by n of the place e required completion & off by off
Whom when (Where) required (Money) evaluation Date
(Time) arrangemen
ts
PDSA

TOOL

PLAN

TINDAKAN

DO

STUDY

ACTION