ANALISIS PENYEBAB KEGAGALAN KOMPONEN RADIO KAYU DI CV. PIRANTI WORK

Abstract Failure occurs when the workpiece stop doing one or more functions that should be good before self service expected to achieve, it can be said workpiece fails or is damaged. Failure can affect the output of production. As in the Piranti Work failures affecting production yield. At the Root Cause Analysis (RCA) an event or problem is identified the root cause. Root Cause Analysis (RCA) is a process used in investigating and classifying the roots of the problems incidents that may affect the safety, health, environment, quality, reliability and production. Root Cause Analysis (RCA) on the CV. Piranti Works is used to identify failures that affect the outcome of production. In this study integrated Fault Tree Analysis (FTA) and Barrier Analysis as a method to identify the root cause of the problem. Fault Tree Analysis describes how an event affects the occurrence of failure. While on Barrier Analysis to determine the barriers that occur so that it can lead to failure. So that improvements can be made based on the root of the problem is found and the failures are not re-occur

The problem with root cause analysis

Attempts to learn from high-risk industries such as aviation and nuclear power have been a prominent feature of the patient safety movement since the late 1990s. One noteworthy practice adopted from such industries, endorsed by healthcare systems worldwide for the investigation of serious incidents, (1-3) is root cause analysis (RCA). Broadly understood as a method of structured risk identification and management in the aftermath of adverse events, (1) RCA is not a single technique. Rather, it describes a range of approaches and tools drawn from fields including human factors and safety science (4,5) that are used to establish how and why an incident occurred in an attempt to identify how it, and similar problems, might be prevented from happening again.(6) In this article, we propose that RCA does have potential value in healthcare, but it has been widely applied without sufficient attention paid to what makes it work in its contexts of origin, and without adequate customisation for the specifics of healthcare. (7,8) As a result, its potential has remained under-realised (7) and the phenomenon of organisational forgetting (9) remains widespread (Box 1). Here, we identify eight challenges facing the utilisation of RCA in healthcare and offer some proposals on how to improve learning from incidents

To Fib or Not to Fib: Misdiagnosis of Atrial Fibrillation on Telemetry Case Presentation and Root Cause Analysis

Case presentation, current practices of telemetry management, root cause analysis, goals for improvement, proposed intervention and next steps