by : nadroh br.

sitepu

introducing
M e d i c a t i on
Errors
1. DEFINISI
2. EPIDEMIOLOGI
3. KLASIFIKASI
4. SUMBER KESALAHAN
5. FAKTOR-FAKTOR YANG MEMPENGARUHI ME & RISIKONYA
6. LANGKAH-LANGKAH UNTUK MENCEGAH ME
7. RINGKASAN
 • Medication error adalah suatu
DEFINISI kesalahan dalam proses
pengobatan yang masih berada
dalam pengawasan dan tanggung
jawab profesi kesehatan, pasien

1 atau konsumen, dan seharusnya

dapat dicegah (Cohen, 1991, Basse
& Myers, 1998).
DEFINISI (Lanjutan) • Dalam Surat Keputusan
Menteri Kesehatan RI Nomor
1027/MENKES/SK/IX/2004
disebutkan bahwa pengertian
medication error adalah
1 kejadian yang merugikan
pasien, akibat pemakaian obat
selama dalam penanganan
tenaga kesehatan, yang
sebetulnya dapat dicegah.
 • ME dapat terjadi mulai dari peresepan
DEFINISI (Lanjutan) sampai konsumsi obat oleh pasien
• Masalah & sumber masalah pengobatan
ini melibatkan multidisiplin &
multifaktorial

1 ME dapat terjadi disebabkan:

 Kurang pengetahuan
 Pelabelan obat yang tidak jelas atau salah
 Kesalahan dalam mengidentifikasi pasien
 Penyimpangan/ gangguan mental atau
 Kesalahan memverifikasi px

ME dapat dilakukan oleh Nakes yang

berpengalaman & nakes yang tidak
berpengalaman.
2 EPIDEMIOLOGI
 Fakta yang terjadi:
Hasil cohort study oleh kozer, et al (2005) melibatkan 1532
peresepan pasien anak-anak di ICU 12 rumah sakit di amerika
yang disampling secara random, sekitar 10% di antaranya

2 mengalami medication error yang terinci menjadi prescribing error

(10.1%) dan drug administration error (3,9%). Medication error
pada anak-anak merupakan kejadian yang penting, jika
dibandingkan dengan kejadian pada dewasa maka potensi
merugikannya tiga kali lipat. Dari studi terhadap 10788 peresepan
pediatri, 616 potensial untuk terjadi error.
3. Klasifikasi ME
 SUMBER ME

4 Kejadian medication error dibagi dalam 4 fase, yaitu:

a. fase prescribing, > pd penulisan R/ (9T + 1 W)
b. fase transcribing,
c. fase dispensing dan
d. fase administration oleh pasien.

Pada fase transcribing, error terjadi pada saat pembacaan resep untuk proses dispensing.
Error pada fase dispensing terjadi pada saat penyiapan hingga penyerahan resep oleh
petugas RS/ apotek.
Sedangkan error pada fase administration adalah error yang terjadi pada proses
penggunaan obat. Fase ini dapat melibatkan petugas apotek dan pasien atau keluarga px
Getting Started with Templates
Faktor Yg
Mempengaruhi ME

5
 LANGKAH-LANGKAH UNTUK MENCEGAH ME

• Checking patient’s identity.

• Ensuring dosage calculations are cross
checked independently by another health care
professional before drug is administered
• Ensuring medication given at correct time

• Minimizing interruptions during drug rounds

 Drugs commonly associated with
medication errors
• Analgesics -

– Unnecessary use of opioid analgesics (over sedation of

patient)
– Errors reported are due to wrong route of
administration
– Failure to monitor clinical parameters (heart rate,
respiration & blood pressure), resulted in major adverse
outcomes related to opioid use

28
• Antibiotics-
Irrational use

• Anticoagulants-
Inadequate therapeutic dosing
Failure to monitor blood levels

• Cardiovascular agents-
Errors due to overdose
Failure to identify drug-drug interactions due to
polypharmacy
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• Diabetic medications-
– Overdose of hypoglycemic drugs (insulin)

– Overenthusiastic patients trying to keep blood glucose

within normal limits

– Failure to take drugs in relation to meals

– This group of drugs signifies importance of patient

education by treating physicians
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 LOOK ALIKE SOUND ALIKE
• Existence of confusing drug names is one of the most
common causes of medication error

• With thousands of drugs currently in market, potential for

error due to confusing drug names is significant

• Contributing factors are

– illegible handwriting,
– incomplete knowledge of drug names
– newly available products,
– similar packaging or labelling
– similar clinical use

– Similar strengths, dosage forms, frequency of administration 31

 Major effect on therapeutic
success
Brand name(Generic name) Brand name(Generic name)

Benzol (Danazol) Benzole (Albendazole)

Alparazole (Alprazolam) Adprazole (Omeprazole)

Amsat (Ampicillin) Amset (Amlodipine)

Adcom (Telmisartan) Adcon (Fluconazole)

Alflox (Norfloxacin) Alfox (Oxcarbazepine)

Dazolic (Ornidazole) Dazolin (Sertraline)

32
 Minor effect on therapeutic
success
Brand name(Generic name) Brand name(Generic name)

Aquamide (Furosemide) Aquazide (Hydrochlorthiazide)

Disprin (Aspirin 350mg) Dospin (Aspirin 75mg)

Epitab (Phenytoin) Epitan (Phenobarbitone)

Ostofit (Glucosamine) Ostrobit (Ca. carbonate)

Wormnil (Mebendazole) Wormonil (Albendazole)

33
 No significant effect on
therapeutic success
Brand name(Generic name) Brand name(Generic name)

Avcif (Cefixime) Avcip (Ciprofloxacin)

Atmox (Amoxicillin) Atrox (Roxithromycin)

Cefit (Cefixime) Cefiz (Cefpodoxime)

Ceftab (Cefuroxime) Ceftas (Cefixime)

Deplin (Sertraline) Depnil (Clomipramine)

34
35
 Steps to prevent medication
errors
Targeted physician education on optimal medication

use
Inclusion of clinical pharmacists in decision making
activities
Computerized order entry by prescriber & medication
checking

Standardize processes & equipment

Avoid use of unknown abbreviations & symbols

Double check patients having allergies before

prescribing 37
 Preparing medicine in well lighted room

Check the expiry date of the drug before

administration

Medication Reconciliation

Standardised ordering and administration

Training, education, and organisational interventions 38

 Six step approach by WHO for
good prescribing
• Evaluate & clearly define patient’s problem

• Specify therapeutic objectives

• Select appropriate drug therapy: P-drug & STEPS approach

(Safety, Tolerability, Effectiveness, Price, Simplicity)

• Initiate therapy with appropriate details

• Give information, instructions & warnings

• Evaluate therapy regularly (e.g. Monitor treatment results) 39

 Role of regulatory authorities
• Important role in preventing medication errors

• Review of drug labels & nomenclature greatly enhances

preventive strategies

• FDA provides guidance to industry to maintain proper drug labels

• Public education by regulatory agencies improves medication use

• Emphasis laid on having package insert in vernacular languages

40
 Role of organizations
• Computer software installation by FDA to analyze similar
drug names

• Potentially confusing names rejected

• FDA reviews 300 brand names in a year before they are

marketed to avoid confusion of LASA drugs

• FDA encourages pharmacists & other health professional to

report any medication errors

41
 Role of prescribers
• Doctors should have knowledge of generic names & brand
names of available drugs in their local setting

• Specify dosage form, drug strength & complete directions

on prescriptions

• Using both brand name & generic name on prescription

• Purpose of medication

• Legible handrwiting
42
 Role of Pharmacist
• Refer back to doctor if any confusion

• Basic knowledge of dosing regimens for commonly used

drugs

• Computer reminder for serious confusing name pairs to

avoid errors in prescription

• Stickers of ‘Alert’ in areas where LASA drugs stored

• In case of wrong prescription, pharmacist should not react

in front of patient 43
 Role of nursing staff
• Education & proper training important in reducing
medication related errors

• Most errors do not reach patient because of barrier role

played by a nurse

• Independent calculations of paediatric doses by more than

one person

• Should be aware of correct storage requirements for drugs

• Development of standardized dose & rate charts for

44
products such as vasoactive drugs
 Patient & Physician education
• Regular short courses/training to junior residents by academic
institution for good prescription writing practices

• Prescriber should also consider –

– Age of patient
– Any physical disability
– Weak eye sight, before prescribing

• Patient educated regarding correct use of prescription & over

the counter medicines

45
• Patient should confirm name & strength of prescribed drugs
before leaving doctor’s office

• Educated about the storage conditions of drugs (e.g. Insulin)

• Keeping medicines away from reach of children also should

be emphasized

• Patient should carry all previous prescriptions to avoid

repeating the drug or notice any change in prescriptions

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 KESIMPULAN
Summary
Stay alert !
Question !
Learn !

Selamat Belajar &

Ujian Semoga Sukses