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    Prinsip Keamanan Pengobatan

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    Anastasia Yovita Sari
    The document discusses medication safety principles and identifies several key issues: 1. Medication treatment has become more complex with more drug varieties and interactions that can cause harm. 2. Medication errors can occur at any step in the medication use process from prescribing to administering to monitoring. 3. Certain medications like concentrated electrolytes and look-alike/sound-alike drugs are "high-alert medications" that require extra precautions due to high risk of errors causing serious harm. Hospitals should have clear policies on storage, labeling and access to prevent inadvertent administration of these drugs. 4. Understanding why medication errors happen through reporting and learning from errors is important to continuously improve medication safety.

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    Prinsip Keamanan Pengobatan

    Uploaded by

    Anastasia Yovita Sari
    39 views39 pages
    The document discusses medication safety principles and identifies several key issues: 1. Medication treatment has become more complex with more drug varieties and interactions that can cause harm. 2. Medication errors can occur at any step in the medication use process from prescribing to administering to monitoring. 3. Certain medications like concentrated electrolytes and look-alike/sound-alike drugs are "high-alert medications" that require extra precautions due to high risk of errors causing serious harm. Hospitals should have clear policies on storage, labeling and access to prevent inadvertent administration of these drugs. 4. Understanding why medication errors happen through reporting and learning from errors is important to continuously improve medication safety.

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    Prinsip Keamanan Pengobatan(1)

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    The document discusses medication safety principles and identifies several key issues: 1. Medication treatment has become more complex with more drug varieties and interactions that can cause harm. 2. Medication errors can occur at any step in the medication use process from prescribing to administering to monitoring. 3. Certain medications like concentrated electrolytes and look-alike/sound-alike drugs are "high-alert medications" that require extra precautions due to high risk of errors causing serious harm. Hospitals should have clear policies on storage, labeling and access to prevent inadvertent administration of these drugs. 4. Understanding why medication errors happen through reporting and learning from errors is important to continuously improve medication safety.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    39 views39 pages

    Prinsip Keamanan Pengobatan

    Uploaded by

    Anastasia Yovita Sari
    The document discusses medication safety principles and identifies several key issues: 1. Medication treatment has become more complex with more drug varieties and interactions that can cause harm. 2. Medication errors can occur at any step in the medication use process from prescribing to administering to monitoring. 3. Certain medications like concentrated electrolytes and look-alike/sound-alike drugs are "high-alert medications" that require extra precautions due to high risk of errors causing serious harm. Hospitals should have clear policies on storage, labeling and access to prevent inadvertent administration of these drugs. 4. Understanding why medication errors happen through reporting and learning from errors is important to continuously improve medication safety.

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    Prinsip

    Keamanan
    Pengobatan
    Ristina Mirwanti
    Issue

     Pengobatan saat ini semakin kompleks


     Jumlah dan variasi obat semakin meningkat
     Pengobatan memiliki efek kuratif & efek samping
     Efek samping dari pengobatan dapat menyebabkan
    kematian  interaksi obat (?); KTD (?); kesalahan
    administrasi (?)
     Medikasi : melibatkan berbagai profesi  komunikasi
    yang baik.
    Istilah

     Side-effect
    A side-effect is a known effect, other than that primarily
    intended, relating to the pharmacological properties of a
    medication
     Adverse reaction
    An adverse reaction occurs when unexpected harm
    results from a justified action, when the correct process
    was followed for the context in which the medication was
    used
     Error
    An error is a failure to carry out a planned action as intended
    or the application of an incorrect plan .
     Adverse event
    An incident in which a patient is harmed.
     Adverse drug event
    An adverse event involving medication (an adverse drug
    event) may be preventable (e.g. the result of an error) or may
    not be preventable(e.g. an unexpected allergic reaction in a
    patient taking a medication for the first time, as described
    above).
     Adverse drug reaction
    Any response to a medication that is noxious and
    unintended. This WHO definition includes injuries that are
    judged to be caused by the drug and excludes injuries due
    to drugs that are caused by error.
     Medication error
    Any preventable event that may cause or lead to
    inappropriate medication use or patient harm while the
    medication is in the control of the health-care
    professional, patient or consumer
     Prescribing
    A prescription is an order to take certain medications.

     Medication error
    A medication error may result in:
     an adverse event, in which a patient is harmed;
     a near miss, in which a patient is nearly harmed;
     neither harm nor potential for harm.

    Medication error is a common cause of preventable patient harm.


    Angka Kejadian

     The IOM estimates that in the USA there is one


    medication error per hospitalized patient per day,
     1.5 million preventable adverse drug events per year,
     and 7000 deaths per year from medication errors in
    hospitals in that country.
     Only 15% of the prescribing errors that are made reach
    patients; the others are caught in time by pharmacists and
    other health-care workers
    Steps in using medication

    – prescribing,
    – dispensing,
    – administering,
    – monitoring.
    The use of medication
    carries risks
    Prescribing
    – Errors may involve prescribing for the wrong patient, prescribing the
    wrong dose, prescribing the wrong drug, prescribing the wrong
    route or the wrong time for drug administration.
    Cause of Prescribing Errors :
     Inadequate knowledge about drug indications,
    contraindications and drug interactions
     Failure to consider physical, cognitive, emotional and
    social factors that might alter prescribing, such as
    allergies, pregnancy, co-morbidities, health literacy and
    other medications the patient may be taking
     Inadequate communication (writing / verbal)
     Mathematical errors made in calculating doses
    – Dispensing
    Higher pharmacy workload, defined as the number of
    prescriptions dispensed per pharmacist work hour, led to
    increased risk of dispensing a potentially unsafe
    medication.
    – Administering
    Error : the wrong dose of a drug being given to the wrong
    patient, by the wrong route, at the wrong time, or the
    wrong drug being used.
    Administration errors can result from
     inadequate communication,
     slips or lapses,
     lack of checking procedures,
     lack of vigilance and calculation errors, as well as suboptimal
    workplace,
     medication packaging design
     inadequate documentation
     calculation mistakes for IV drugs (e.g. drops/h or drops/min, ml/h
    or ml/min)
    Monitoring Errors, include :
     inadequate monitoring for side-effects,
     not ceasing medication once the prescribed course has been
    completed or is clearly not helping the patient
     not completing a prescribed course of medication.

    Monitoring errors occur when drug levels not measured or


    measured but not checked or acted upon.

    These errors often involve communication failures.


    Contributory factors for
    medication errors

    Adverse medication events are frequently multifactorial in


    nature, combination of events that together result in
    patient harm.
     Patient factors
     Staff factors
     Workplace design factors
     Medication design factors
     Other technical factors
    Some ways to make
    medication use safer

    – Use generic name


    – Tailor your prescribing for individual patients
    – Learn and practise collecting complete medication histories
    – Know which medications used in your area are associated
    with high risks of adverse events
    – Be very familiar with the medications you prescribe
    – Use memory aids
    – Remember the 5 Rs when prescribing and administering
    medication (5 Benar)
    – Communicate clearly
    – Develop checking habits
    – Encourage patients to be actively involved in their own care
    and the medication process.
    – Educate your patients about their medication(s) and any
    associated hazards.
    – Communicate plans clearly with patients.
    – Remember that patients and their families are highly
    motivated to avoid problems
    Obat yang Perlu
    Diwaspadai (High-Alert
    adalah sejumlah obat-obatan yang
    Medications)
    memiliki risiko tinggi menyebabkan bahaya
    yang besar pada pasien jika tidak
    digunakan secara tepat (drugs that bear a
    heightened risk of causing significant
    patient harm when they are used in error
    (ISMP - Institute for Safe Medication
    Practices).
    Obat yang Perlu Diwaspadai (High-Alert
    Medications) merupakan obat yang
    persentasinya tinggi dalam menyebabkan
    terjadinya kesalahan / error dan / atau
    kejadian sentinel (sentinel event), obat yang
    berisiko tinggi menyebabkan dampak yang
    tidak diinginkan (adverse outcome)
    termasuk obat-obat yang tampak mirip
    (Nama Obat, Rupa dan Ucapan Mirip /
    NORUM, atau Look-Alike Sound-Alike /
    LASA), termasuk pula elektrolit konsentrasi
    tinggi.
    – Jadi, obat yang perlu diwaspadai merupakan obat yang
    memerlukan kewaspadaan tinggi, terdaftar dalam kategori
    obat berisiko tinggi, dapat menyebabkan cedera serius
    pada pasien jika terjadi kesalahan dalam penggunaan.
    Intent of IPSG.3

    – Obat-obatan yang perlu diwaspadai: obat yang sering


    menyebabkan kejadian sentinel atau KTD
    – Obat yg Perlu diwaspadai :
    – NORUM (Nama Obat Rupa dan Ucapan Mirip) , Look Alike
    Sound Alike / LASA).
    – Elektrolit konsentrat : (kalium klorida 2meq/ml atau yang
    lebih pekat, kalium fosfat, natrium klorida lebih pekat dari
    0.9%, dan magnesium sulfat =50% atau lebih pekat-).
    – Kesalahan ini bisa terjadi secara tidak sengaja atau bila
    perawat tidak mendapatkan orientasi dengan sebelum
    ditugaskan, atau pada keadaan gawat darurat.
    Lanjutan……..
    Cara untuk mengurangi atau mengeliminasi KTD:
    – meningkatkan proses pengelolaan obat-obat yang perlu diwaspadai
    termasuk memindahkan elektrolit konsentrat dari unit pelayanan
    pasien ke farmasi.
    – RS punya Kebijakan dan/atau prosedur
    – Daftar obat-obat yang perlu diwaspadai berdasarkan data yang
    ada di rumah sakit
    – identifikasi area mana saja yang membutuhkan elektrolit
    konsentrat, seperti di IGD atau kamar operasi
    – pemberian label secara benar pada elektrolit
    – penyimpanannya di area tersebut, sehingga membatasi akses
    untuk mencegah pemberian yang tidak disengaja / kurang hati-
    hati.
    KCl Concentrated
    – Concentrated potassium chloride has been identified as a
    highrisk medication by organizations in Australia, Canada,
    and the United Kingdom of Great Britain and Northern
    Ireland (UK) (1).
    – In the US, 10 patient deaths from misadministration of K
    Cl concentrated solution were reported to the Joint
    Commission in just the first two years of its sentinel event
    reporting programme: 1996–1997 (1).
    – In Canada, 23 incidents involving KCl mis-administration
    occurred between 1993 and 1996 (2).
    – There are also reports of accidental death from the
    inadvertent administration of concentrated saline solution
    (3).
    LASA (LOOK ALIKE SOUND
    ALIKE)
    NORUM ( NAMA OBAT RUPA
    MIRIP)
     hidraALAzine  hidrOXYzine
     ceREBYx  ceLEBRex

     vinBLASTine  vinCRIStine
     chlorproMAZINE
     chlorproPAMIDE
     glYBURIde
     glipiZIde
     dOXOrubicine
     DAUNOrubicine

    Tulis yang berbeda dengan huruf KAPITAL


    Look Alike Sound Alike
    Look alike
    LASA
    LASA
    Measurable Elements of IPSG.3
    (Elemen Penilaian IPSG.3)
    1. Kebijakan dan/atau prosedur dikembangkan agar memuat proses
    identifikasi, menetapkan lokasi, pemberian label, dan penyimpanan
    elektrolit konsentrat.
    2. Implementasi kebijakan dan prosedur
    3. Elektrolit konsentrat tidak boleh disimpan di unit pelayanan pasien
    kecuali jika dibutuhkan secara klinis dan tindakan diambil untuk
    mencegah pemberian yang kurang hati-hati di area tersebut sesuai
    kebijakan.
    4. Elektrolit konsentrat yang disimpan di pada unit pelayanan pasien
    harus diberi label yang jelas, dan disimpan pada area yang dibatasi
    ketat (restricted).
    Information for patient and family can be both verbal and written and
    should cover the following aspects:
     name of the generic drug;
     purpose and activity of the medication;
     dose, route and administration schedule;
     special instructions, directions and precautions;
     common side-effects and interactions;
     how the effects of the medication (e.g. efficacy, side-effects, etc.)
    will be monitored.
    Report and learn from medication errors
    – Discovering more about how and why medication errors
    occur is fundamental to improving medication safety.
    – Whenever an adverse drug event or near miss occurs, there
    is an opportunity for learning and improving care.
    Summary

     Medications can greatly improve health when used wisely


    and correctly.
     Nevertheless, medication errors are common and cause
    preventable human suffering and financial cost.
     Remember that using medications to help patients is not
    a risk-free activity.
     Know your responsibilities and work hard to make
    medication use safe for your patients.
    Terima kasih

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