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 : ……………..

Potential Failure Mode Potential Effects of Potential Cause of

Likelihoo
d
Detection

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
0
0
0
0
0
0
0
0
0
0
0

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

 Potential Failure Mode Potential Effects of Potential Cause of Current Controls

Likelihoo
d
Detection

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 : ……………..

Potential Failure Mode Potential Effects of Potential Cause of Current Controls

Likelihoo
d
Detection

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 : ……………..

 Potential Failure Mode Potential Effects of Potential Cause of Current Controls

Likelihoo
d
Detection

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 : ……………..

Potential Failure Mode Potential Effects of Potential Cause of Current Controls

Likelihoo
d
Detection

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
 Severity

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

slh pemberian obat pasien cedera BLM ADA SPO 4 3 2

4 2 2
3 2 1
3 3 2
4 2 2
3 2 4
4 2 2
RPN

24
16
6
18
16
24
16
Pareto Analysis

[Brief Project Description]

[Date]

[Chart Title]
1 100%

Cumulative %
0.9
Defects

0.8 80%

0.7

0.6 60%

0.5

0.4 40%

0.3

0.2 20%

0.1 [42]

0 Failure Mode 0%

Vital Few Useful Many Cumulative% Cut Off %

[42]

#DIV/0!

Cumulative Percentage Cutoff: 80%

# Failure Mode Defects Cumulative%
1 #DIV/0!
2 #DIV/0!
3 #DIV/0!
4 #DIV/0!
5 #DIV/0!
6 #DIV/0!
7 #DIV/0!
8 #DIV/0!
9 #DIV/0!
10 #DIV/0!
11 #DIV/0!
12 #DIV/0!
13 #DIV/0!
#DIV/0!
#DIV/0!

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 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