BORANG DAFTAR RISIKO

PEJABAT KESIHATAN DAERAH SEBERANG PERAI SELATAN

[DAFTAR RISIKO] UNIT FARMASI

Pemantauan / Semakan
Pengenalpastian Risiko Analisa Risiko
Semula

Kebarangkalian

Kebarangkalian
Tahap Risiko

Tahap Risiko
Kawalan sedia ada Kawalan tambahan Catatan

Komen
Impak

Impak
No Proses Isu Risiko Peluang

1 Pendispensan Ubat- Kesilapan pembekalan Medication Error Tiada 1. Semak silang antara anggota yang berbeza untuk tugas Risiko terkawal, Pemantauan
Ubatan ubat kepada pesakit pengisian dan pendispensan ubat Kekalkan menggunakan
2. Guna Tallman Lettering pada label ubat tindakan - QAP1
3. Menggunakan sistem PHIS untuk mencetak label arahan ubat kawalan sedia - Medication Error
4. Susunatur dan label ubat mengikut panduan LASA/HAM/ ada reporting (MER)
Tallman Lettering - Incident Reporting
5. Nombor giliran diberi kepada setiap pesakit
6. Pengesahan pesakit baru menggunakan kad pengenalan
7. Meminta pesakit menyebut nama pesakit sebelum ubat
didispen
8. Padankan nombor giliran pesakit dengan nombor giliran pada
preskripsi.
KK Bukit Panchor 2 3 6 KK Bukit Panchor 2 3 6

KK Bdr. Tasek Mutiara 2 3 6 KK Bdr. Tasek Mutiara 2 3 6

KK Nibong Tebal 2 3 6 KK Nibong Tebal 2 3 6

Kk Sg Acheh 2 3 6 Kk Sg Acheh 2 3 6

KK Valdor 2 3 6 KK Valdor 2 3 6

KK Sungai Bakap 2 3 6 KK Sungai Bakap 2 3 6

2 Pemantauan tarikh luput Ubat luput dalam Pembaziran Ubat tiada 1. First Expiry First Out (FEFO) diamalkan Risiko terkawal, Pemantauan
ubat di stor ubat simpanan stok 2. Label “use me first” digunakan untuk ubat hampir luput di rak Kekalkan menggunakan :
3. Pemeriksaan stok setiap 4 bulan tindakan - KEW.PS-6
4. Pemantauan ubat lambat bergerak berdasarkan KEW.PS-6 dan kawalan sedia - QAP-4
tawaran ke PTJ lain akan dibuat setiap bulan. ada

KK Bukit Panchor 3 3 9 KK Bukit Panchor 3 3 9

KK Bdr. Tasek Mutiara 3 3 9 KK Bdr. Tasek Mutiara 3 3 9
KK Nibong Tebal 3 3 9 KK Nibong Tebal 3 3 9
Kk Sg Acheh 3 3 9 Kk Sg Acheh 3 3 9
KK Valdor 3 3 9 KK Valdor 3 3 9
KK Sungai Bakap 3 3 9 KK Sungai Bakap 3 3 9
3 Melaksanakan Pembelian Paras minimum dan Stok berlebihan atau tidak tiada 1) Menetapkan paras minimum, penimbal & maksimum Risiko terkawal, Pemantauan:
dan Pesanan atau Inden maksimum stok di luar mencukupi penyimpanan stok Kekalkan - KPI Simpanan Stok
Ubat dan Consumables julat tindakan (AP1-A)
2) Semakan kuantiti pembelian oleh dua orang pegawai farmasi kawalan sedia - Laporan
(penyokong dan pelulus) sebelum proses pembelian ada Pembekalan Ubat 2
Minggu
3) Membuat pinjaman/ tawaran stok keluar/ ‘barter trade’ jika
stok berlebihan/ tidak mencukupi

4) Menggunakan ROA (Reorder Advice) sebelum membuat

pembelian

Unit Farmasi Logistik 2 3 6 Unit Farmasi Logistik 2 3 6

1 /10 / 684022422.xlsx
 QAP 1:
QAP 1
Percenta ge of pres cri pti ons wrongl y fi l l ed a nd de tecte d before di s pens i ng to the tota
sasaran 0.0%
capai 0.0449% STATE : PULAU PINANG R

NO. NAME OF FACILITY

Received

5 PKD Seberang Perai Selatan

5.1 KK Bkt. Panchor 9,058

5.2 KK Nibong Tebal 9,295

5.3 KK Bandar Tasek Mutiara 20,373

5.4 KK Sg. Acheh 6,084

5.5 KKIA Sg Bakap 0

5.6 KK Valdor 0

Jumlah 44,810

MER
2020 , 1 kes
Laporan Kes Keselamatan Pengubata
No. PTJ Date Time Location of Types of Error D
event event event ( 1. prescribing error 2. er
Ward/A&E/O omission error 3.
PD/IPD/CLINI wrong time error 4.
C/LAIN-LAIN unauthorised drug 5.
etc… dose error 6.
dosage form error 7.
drug preparation error
8. route of
administration error
9. administration error
10. deteriorated drug
error
11. monitoring error
12. compliance error
13. other medication
error

C.
w
1 KKBTM 10.3.2020 5.07pm Pharmacy Unauthorized drug error di
 error
11. monitoring error
12. compliance error
13. other medication
error

C.
w
1 KKBTM 10.3.2020 5.07pm Pharmacy Unauthorized drug error di
C
25

Insident reporting tiada

2020 - 0

QAP 4 - pelupusan ubat

2020-0

QAP 3 : Percentage Of Value Of Stock Disposed To Value

State : PULAU PINANG __________________

Year : _____2020_____________

Total Value of Stock Disposed Total Value

No. Facility
(RM) Handled

1 PEJABAT 0 6,645
KESIHATAN
DAERAH
SEBERANG
PERANG PERAI
SELATAN

TOTAL
Standard: 0%

Formula :

Percentage of value of stocks disposed = Total value of stock disposed x 1

Total value of stock handled
 Formula :

Percentage of value of stocks disposed = Total value of stock disposed x 1

Total value of stock handled

KPI Simpanan Stok (AP1-A) AP1-A: PERATUS FASILITI KEMENTERIAN KESIHATAN MA

sasaran : 1-3 bulan
capai : 1-3 bulan

LAPORAN SIMPANAN STOK UNTU

HOSPITAL / PKD JAN FEB MAC

PKD SEBERANG PERAI SELATAN 1.79 2.98 2.64

 cte d before di s pens i ng to the tota l number of pres cri pti ons counterchecke d Sta nda rd : 0%

REPORTING PERIOD : OKT- DIS 2020

OPD
Total number of prescriptions

Wrongly fi lled & detected before Number of errors detected

Received Counterchecked (a)
dispensing (b)

9,058 8,951 2 2

9,295 9,295 3 3

20,373 20,180 11 11

6,084 6,084 4 4

0 0 0 0

0 0 0 0

44,810 44,510 20 20

Keselamatan Pengubatan Bulan Jan-Dis 2020

of Types of Error Description of Process occurred Reached Administer Result to pt Error Error cause
( 1. prescribing error 2. errors prescribing/ pt ed / taken eg: death/type Outcome /Contributio
&E/O omission error 3. dispensing (including (Yes/No) by pt of harm/ Category Factors (
LINI wrong time error 4. filling) / (Yes/No) additional (A/B/C/D inexperien
AIN unauthorised drug 5. administrastion/doc monitoring /E/F/G/H personnel/fai
dose error 6. umentation/others /I) to adhere t
dosage form error 7. (pls specify…) work procedu
drug preparation error Look alike
8. route of medication/pa
administration error ging/ peak
9. administration error hour/illegible
10. deteriorated drug Pt informatio
error record
11. monitoring error inaccurate/ st
12. compliance error arrangemen
13. other medication sound alike
error wrong labell

C. Cloxacillin 250mg
C-Actual
was filled and Stock arrangem
Filling and dispensing error-
Unauthorized drug error dispensed instead of Yes No No harm Sound alike
eror caused no
 error record
11. monitoring error inaccurate/ st
12. compliance error arrangemen
13. other medication sound alike
error wrong labell

C. Cloxacillin 250mg
C-Actual
was filled and Stock arrangem
Filling and dispensing error-
Unauthorized drug error dispensed instead of Yes No No harm Sound alike
eror caused no
C Amoxycillin medication
harm
250mg.

QAP 3 FORM

tock Disposed To Value of Stock Handled

Percentage Of Value Of
Stock Disposed Total Value of Stocks
Stocks Disposed To Value of
RM) Handled (RM)
Stocks Handled
0 6,645,535 0.00% (UBAT, BUKAN
UBAT, VAKSIN)

Standard: 0%

otal value of stock disposed x 100%

Total value of stock handled
 otal value of stock disposed x 100%
Total value of stock handled

ENTERIAN KESIHATAN MALAYSIA (KKM) YANG BERJAYA MENCAPAI PARAS SIMPANAN STOK UBAT YANG

MPANAN STOK UNTUK UBAT (TERMASUK VAKSIN) FASILITI TAHUN 2020

JAN FEB MAC APR MEI JUN JULAI OGOS SEPT OKT NOV DIS

1.79 2.98 2.64 2.75 2.94 2.35 2.23 2.51 2.53 2.83 2.97 2.14

sasaran : 1-3 bulan

 Percentage of
prescriptions
wrongly fi lled and
r of errors detected
(b) / (a) x 100%
* up to 4 decimal
points

2 0.0223

3 0.0323

11 0.0545

4 0.0657

0 #DIV/0!

0 #DIV/0!

20 0.0449

Error Error causes Personel Involved Action suggested or taken

Outcome /Contribution
Category Factors (
(A/B/C/D inexperiend
/E/F/G/H personnel/failure
/I) to adhere to
work procedure.
Look alike
medication/packa
ging/ peak initial involve detected
hour/illegible Rx/ error in the by
Pt information/ error
record
inaccurate/ stock
arrangement/
sound alike/
wrong labelling

C-Actual
Stock arrangement, CQDC, Sound alike label on the
error- Pharmaci Pharmaci Patient's
Sound alike bin, rearrangement of
caused no st st caregiver
 record
inaccurate/ stock
arrangement/
sound alike/
wrong labelling

C-Actual
Stock arrangement, CQDC, Sound alike label on the
error- Pharmaci Pharmaci Patient's
Sound alike bin, rearrangement of
caused no st st caregiver
medication medication bin
harm
TOK UBAT YANG

020

NOV DIS

2.97 2.14