No.

Form : FM-TR-IH-
06
Revisi : 0

RISK ASSESSMENT (HIRA) FORM Tgl. Eff : 5 Sept

2022

Department /Instalasi: Jenis Industri: Pelayanan Kesehatan (Rumah Sakit)

Instalasi Gawat Darurat

;
Tim Kajian Risiko: dr. Wendy Rachmadhany, Heriyanto, S. Kom, Asung Sukoco, Amd. Kes, Magdalena M, S. KM Disetujui oleh:
Ketua Komite K3 Rumah Sakit

Tanggal Dilakukan: 05/09/2022 Tanggal Tinjau Ulang Berikutnya:

06/09/2022

Identifikasi Bahaya Evaluasi Risiko Pengendalian Risiko

1a. 1b 1c. 1d. 2a. 2b. 2c. 2d. 3a 3b 3c 3d 3e 3f

No Aktifitas Pekerjaan Bahaya Potensi Kecelakaan, Pengendalian yg Kepara Probal Tingkat Pengendalian Keparah Proba Tingkat Tindak Lanjut Keterangan
Dampak kesehatan, sudah ada han ilitas Risiko tambahan an bilita Risiko Oleh
kerugian material kejadi s
an

1 Kejut Jantung/Defibrilator Bahaya Listrik Tegangan Bahaya tersengat arus SOP 3 1 3 Pelatihan dan 2 1 2 Ka. BIdang Medis ,
Tinggi listrik kalibrasi alat ka. Instalasi IGD

Bahaya Fisik Terjadi luka bakar pada Pemakaian APD 2 1 2 Pelatihan dan 1 1 1 ka. Bidang
pasien dan tenaga medis (Sarung Tangan Supervisi Pendidikan dan
akibat sengatan listrik Latex) dan GEL Latihan, Ka.
Instalasi IGD

2 Pemasangan infus/IV line Bahaya FIsik Tertusuk Jarum Abocath SOP 2

*RPN - Risk Prioritization Number
Risk Assessment Matrix
Risk Prioritisation Number = Severity x Likelihood
Severity Table

Pt Severity level Workplace Safety Workplace Health Environment Fire Damage Downtime Incurred

Fatality, Acute Poisoning, More Than $10 More than 1 year for
Failure of Major Spills to Outside Campus
single or multiple Bodily Functions million damages full re-instatement

5 Critical
Permanent Body Infection with No Infection - outside
Injury or Loss of Use Known Cure Campus area
for more than 30 days

Injury requiring 30 days Moderate exposure,

of hospitalisation Reversible injury to More Than $1 More than 3 months
Bodily Functions on Spills to Outside Building million damages for full re-instatement
and/or medical leave prolong recovery
4 Very Serious
Temporary Body Injury
or Loss of Use for more Infection with Infection - outside
Known Cure but Building area but within
than 10 days but not extensive treatment Campus
exceeding 30 days

Mild exposure,
Injury requiring 10 days Reversible injury to Spills to Outside More Than $100k More than 1 month for
of hospitalisation Bodily Functions with Laboratory/Room damages full re-instatement
and/or medical leave less than 30 days
recovery
3 Serious

Temporary Body Infection with Infection - outside

Injury or Loss of Use Known Cure but Laboratory area but
for up to 10 days extensive treatment within building

Very Mild exposure,

Injury requiring Reversible injury to Spills to Outside More Than $10k More than 5 days for
maximum of 3 days of Bodily Functions with Workplace but within damages full re-instatement
medical leave only less than 3 days laboratory
recovery
2 Marginal

Temporary Body Infection with Infection - outside

Injury or Loss of Use Known Cure but workplace but within
for 3 days or less treatment needed Laboratory

Very Mild exposure,

Reversible injury to Spills within Workplace Less than $5k No significant
First aid treatment only Bodily Functions with only damages downtime
less than 3 days
1 Negligible recovery

No Infection or infection
No or superficial injury No Exposure with no effects within
workplace

Likelihood Table
Pt Likelihood level Likelihood of Occurrence / Exposure Criteria

5 Frequent Likely to occur many times per year

4 Moderate Likely to occur once per year
3 Occasional Might occur once in three years
2 Remote Might occur once in five years
1 Unlikely Might occur once in ten years
Risk level Determination - 5 x 5 Matrix

SEVERITY
Critical Very Serious Serious Marginal Negligible
(5) (4) (3) (2) (1)

25 20 10
Frequent Operation not Operation not 15 Review at 5
(5) High priority Risk acceptable
permissible permissible appropriate time

Moderate 20 16 12 8 4
Operation not Operation not Review at
(4) permissible permissible High priority appropriate time Risk acceptable
LIKELIHOOD

9
Occasional 15 12 Review at appropriate 6 3
(3) High priority High priority Risk acceptable Risk acceptable
time

10 8
Remote 6 4 2
(2) Review at Review at Risk acceptable Risk acceptable Risk acceptable
appropriate time appropriate time

Unlikely 5 4 3 2 1
(1) Risk acceptable Risk acceptable Risk acceptable Risk acceptable Risk acceptable

Review the risk assessment records every year or whenever there are changes in processes, work activities or upon
any incident occurrence, whichever is earlier.

Action Table
Colour Score Risks Action

Operation not Permissible

16 - 25 High
Stop operation & review controls. If necessary abort
experimentation.

High priority remedial action

12 - 15 Warning Proceed with extreme caution with PI present at all times.

Implement additional (secondary) controls immediately. Review
within 7 days. Emergency control measures shall be in place.

Take remedial action at appropriate time

8 -10 Medium Proceed with care. Additional control is advised. Review shall be
implemented within 30 days.

Risk acceptable: Residual risk

If possible, risk reduction should be further considered,

1-6 Low particularly severity.

There are no imminent dangers. Frequent review shall be in place

especially changes in procedures, materials or environment.
Instructions for using the Risk Assessment form
Header Fill up all sections in the header of the RA form. Note 1: Discuss
with your supervisor/reporting officer on the next review date for the RA. Normally the next review date is up to
one year ahead. The RA is also reviewed:
(1) When there are changes in work
processes/activities (2) After any accidents/incidents
Note 2: Check your Division rules about team or individual
submission for RA

Column 1b Describe the work activity to be carried out. Note: Please do

not fill in names of machines/equipment to be used. Therefore, a computer is not an
activity, but working on a computer is

Column 1c Identify hazard(s) associated with the activity to be carried out. Examples of
hazards include chemical, biological, electrical, mechanical, physical, ergonomics, psychosocial, slip & fall etc.

Column 1d Identify possible accidents/ill health associated with each identified hazard. Examples of
possible accidents/ill health include fires, explosions, cuts, burns, frost bites, fractures etc.

Column 2a Indicate risk control measures that are already in place to eliminate or minimise risks. Methods to
control risks may be analysed according to the Hierarchy of Controls: Elimination, Substitution, Engineering Controls,
Administrative Controls and Personal Protective Equipment (PPE). Elimination of the hazard should take first
priority while PPE should be the last line of defence.
Elimination
Example: Use water based solvents instead of organic based solvents
Substitution
Example: Use a less toxic solvent
Engineering Controls
Example: Use of fume cupboard or gloves boxes Administrative
Controls Example: Work
instructions. Good laboratory practices. Training on proper use of chemicals PPE
Example: Use of safety
eyewear plus respiratory protection, use of gloves

Column 2b S=Severity Severity is the degree

or extent of injury or harm caused by the hazards, or as a result of an accident. Choose the most likely severity
from a value between 1 and 5, rather than the most extreme. Refer to the Risk Matrix tab for the
severity table

Column 2c L=Likelihood Likelihood of occurance

of an accident, incident or ill health is defined as the probability that the said accident, incident or ill health will
happen. Choose the likelihood from a value between 1 and 5. Consider the records of such events happening in
the past when deciding on the likelihood. Refer to the Risk Matrix tab for the likelihood table

Column 2d RPN=Risk Prioritisation Number RPN=Severity X

Likelihood All RPNs should not be more
than 6
Column 3a Additional risk control measures are required when the RPN indicated in column 2d exceeds 6. If the RPN is 6 or
less, enter "NA" in the column

Column 3b S=Severity S may reduce

upon introduction of additional control measures

Column 3c L=Likelihood
L may reduce upon introduction of additional control measures

Column 3d RPN=Risk Prioritisation Number

RPN will reduce upon introduction of additional control measures

Column 3e Enter the name of the person appointed to oversee the implementation of the additional control measures. Enter the
follow-up date.

Column 3f Enter any remarks

 RISK ASSESSMENT FORM
School / Department & Exact Location Of The Work Performed: Project / Work Description: Working with Femtosecond Laser Systems
(Example: SPMS -PAP - Lab A)

Risk Assessment Team (Name/s): Johnny (Team Leader), Alice, Roland, Kenny Approved By Supervisor / Reporting Officer:
(Name, Date & Signature)
Prof Tan (Project Supervisor), 16th March 2012
Date Conducted: 11th March 2012 Next Review Date: 10th March 2013

Hazard Identification Risk Evaluation Risk Control

1a. 1b 1c. 1d. 2a. 2b. 2c. 2d. 3a 3b 3c 3d

S/N Work activity Hazard Possible Accident/ Ill Existing Risk Severity Likelihood RPN* Additional Risk Severity Likelihood RPN*
health to persons, fire or Control Control Measures
property loss

1 Operation of Femtosecond Laser Physical Hazard Severe Eye Injuries Beam blocks and 3 2 6 NA NA NA NA
Systems beam dumps used
to blocked off
laser beams.
Only authorised
users are allowed
to operate the
system.
Users are
equipped with
laser goggles

Electrical Hazard Electrocution due to high Warning signs are 4 3 12 Regular servicing 4 1 4
voltage displayed beside and maintenance
system to warn of laser system by
users of high vendor
voltage Only authorised
users are allow to
operate the
system
*RPN - Risk Prioritization Number
Systems

Control
3e 3f

Follow up by (name) & Remarks

date

NA NA

(Johnny) 13th March NA

2012
 RISK ASSESSMENT FORM
School / Department & Exact Location Of The Work Performed:
(Example: SPMS -CBC - Lab K)

Risk Assessment Team (Name/s): Benny

Date Conducted: 11th March 2012 Next Review Date: 10th March 2013

Hazard Identification Risk Evaluation

1a. 1b 1c. 1d. 2a. 2b.

S/N Work activity Hazard Possible Accident/ Ill Existing Risk Severity
health to persons, fire or Control
property loss

1 Weighing chemicals for the synthesis Irritant Chemicals Irritation when come in Handle under 1
work contact with skin and fumehood.
eyes Put on required
PPE - safety
glasses, lab coat,
long pants,
gloves, covered
shoes.

2 Prepare glassware and add Glass breakage due Cuts on skin/eye due to Inspect glassware 3
chemical into chemical reactor to overpressure flying particles before use.
(chemical reaction) Put on required
PPE - safety
glasses, lab coat,
long pants,
gloves, covered
shoes.
*RPN - Risk Prioritization Number
K ASSESSMENT FORM
Project / Work Description: Chemical works

Approved By Supervisor / Reporting Officer:

(Name, Date & Signature)
Prof Xiao (Project Supervisor), 16th March 2012

Risk Evaluation Risk Control

2c. 2d. 3a 3b 3c 3d 3e 3f

Likelihood RPN* Additional Risk Severity Likelihood RPN* Follow up by (name) & Remarks
Control Measures date

3 3 NA NA NA NA NA NA

3 9 Install pressure 3 1 3 (Benny) Ongoing NA

control / relief
valves
Supervisor to
brief group to pull
down fumehood
sash
 RISK ASSESSMENT FORM
School / Department & Exact Location Of The Work Performed:
(Example: Office)

Risk Assessment Team (Name/s): Joey

Date Conducted: 11th March 2012 Next Review Date: 10th March 2013

Hazard Identification Risk Evaluation

1a. 1b 1c. 1d. 2a. 2b.

S/N Work activity Hazard Possible Accident/ Ill Existing Risk Severity
health to persons, fire or Control
property loss

1 Sorting of documents / Use of paper Contact with sharp Cuts and lacerations to Handle files and 1
edges (from paper hand and fingers documents with
edges and bent care, avoiding
plaster dividers fingers running
along the edge of
papers.
Discard bend
plastic folders.

Punching holes for document Strike by moving Fingers may get injured Proper usage of 1
to be filed parts or caught (crush) during punching hole punch
between moving Do not overload
parts paper for
punching
Maintenance of
hole puncher
 Ergonomic hazard Muscular starins Staff to adopt 3
(repetive similar good ergonomice
action) practice e.g. table
height. Job
rotations; avoid
prolong repetitive
punching
operation.
Brief staff on
proper usage of
hole punch.

*RPN - Risk Prioritization Number

K ASSESSMENT FORM
Project / Work Description: General Office Activities

Approved By Supervisor / Reporting Officer:

(Name, Date & Signature)
Mr Lim (Manager), 16th March 2012

Risk Evaluation Risk Control

2c. 2d. 3a 3b 3c 3d 3e 3f

Likelihood RPN* Additional Risk Severity Likelihood RPN* Follow up by (name) & Remarks
Control Measures date

4 4 Provide finger 1 3 3 Office Staff (April 2012) NA

cots to staff to lift
paper

3 3 NA NA NA NA NA NA
1 3 NA NA NA NA NA NA