MEDICATION

ERROR &
MEDICATION
SAFETY
JUNI 2023
Medication Error
● Adalah kegagalan yang tidak disengaja dalam proses pengobatan yang dapat berpotensi atau
menyebabkan kerusakan pada pasien.
● Hal ini dapat terjadi ketika sistem pengobatan yang lemah dan/atau faktor manusia seperti
kelelahan, kondisi lingkungan yang buruk, atau kekurangan staf mempengaruhi praktik
pengobatan.
● Hal ini dapat terjadi pada setiap tahap proses pengobatan, termasuk pada saat pemberian
obat.
● Semua medication error berpotensi dapat di hindari atau bahkan dicegah dengan meningkatkan
sistem dan praktek pengobatan, termasuk pemesanan,resep, penyiapan, pengeluaran, administrasi
dan pemantauan.
● Mengingat subjeknya sangat luas, hal ini bertujuan untuk menyelamatkan nyawa dari kesalahan
yg tidak aman, dengan secara khusus mengatasi kelemahan pemberian layanan dan
mengembangkan sistem perawatan kesehatan yg lebih efektif

.
 01
Human related
Human Related factor
• Over worked. Beban kerja, yaitu rasio antara
beban kerja dan SDM tidak seimbang.
• Kompetensi
• Distracted, terganggu dering telefon dan
kondisi lingkungan(pencahayaan kurang dan
unit farmasi yg tidak memudahkan tenaga
kesehatan dalam pemberian obat dan
pemberian informasi)
• Stress atau sedang sakit
• Pasien terburu-buru
• Pasien tidak paham obat dan penggunaannya
 02
System Related
System Related Factos

Kurang komunikasi Fasilitas tidak memadai

Komunikasi antar tenaga Kurang meja kerja, kurang

kesehatan rak peyimpanan

Kesalahan Alur kerja Kurang pengawasan

Dari penyiapan hingga Kurangnya pengawasan

obat diserahkan

Disorganized workspace Kesalahan RM dan peresepan

Keluwesan tempat kerja, Penilisan resep tidak

terbaca
 03
Medication
Related
Goals

LASA NORUM Dosis Obat

Look alike sound Nama Rupa Obat Dosis ganda dan
alike Mirip kekuatan dosis
Types of Medication Error
Dispensing Error
• Salah membaca intruksi
• Salah menghitung dosis
• Salah dalam penyimpanan
• Salah mengambil obat dan meracik
• Salah memberi label/ etiket
Administration error
• Waktu pemberian tidak tepat
• Dosis tidak tepat
• Memberikan obat yg seharusnya tidak
diberikan
• Cara pemberian yg tidak benar
(rute,kecepatan)
Prescribing Error (salah peresepan)
• Obat tidak tepat
• Nama obat membingungkan
• Dosis tidak tepat
• Rute pemberian tidak tepat
• Jumlah obat tidak tepat
• Ada kontraindikasi
• Tulisan tidak dapat dibaca
• Penulisan angka & satuan tidak jelas
• Menggunakan istilah & singkatan tidak
lazim
• Intruksi verbal tidak jelas
Kategori Medication Error
Model of medication error “Swiss Cheese”
Dokter salah menuliskan dosis
Apoteker / TTK tidak mengkaji resep / salah menyiapkan obat

Perawat tergesa gesa

Pasien mendapatkan obat yg salah

KTD KTC

Near miss
Peresepan sampai pemberian obat yang aman

Dokter menulis resep Apotik Perawat

• Tulisan jelas & • Telaah resep • Pastikan 5 R(right)

terbaca,lengkap • Obat disiapkan TTK 1. Person
(menuliskan dosis & • Label obat 2. Drug
sediaan) • Double check 3. Dose
• 3 kondisi: 4. Route
1. Alergi obat 5. Time
2. Kontra indikasi High allert drug
3. Interaksi obat
Penyiapan obat (dispensing)
Penyiapan obat (dispensing) adalah rangkaian Tahapan dispensing
proses mulai dari diterimanya resep sampai • Menerima resep
dengan penyerahan obat kepada dokter /perawat • Membaca& mengkaji resep
atau kepada pasien Atau keluarga. • Meracik/menyiapkan obat
• Memberi etiket & label
• Melakukan telaah
Pengkajian resep dilakukan sebelum penyiapan obat • Menyerahkan obat dan edukasi
untuk memastikan bahwa resep benar /legal /akurat Pencegahan
/lengkap dan rasional. Berdasarkan : • Ketepatan obat,dosis,rute,Duplikasi
• Aspek administratif Riwayat alergi,Interaksi obat
• Aspek farmasetik • Kesesuaian dengan peraturan /pedoman
• Aspek klinis penggunaan
Tindak lanjut jika ditemukan kesalahan apoteker • Jika tidak sesuai / resep tidak lengkap
menghubungi dokter penulis resep, dokumentasikan hubungi dokter,perawat>klarifikasi
hasil pengkajian resep • Penyimpanan obat
• Hasil komunikasi • Sesuaikan beban kerja
• Nama dokter • Petugas kompeten & mematuhi SPO
• Tgl dan jam • Faktor lingkungan
• Paraf apoteker • Lakukan telaah obat
Phase 1

Secondary Effects
Mercury is the closest planet to the Sun and
Goals the smallest one in the Solar System—it’s
Study the safety of medication only a bit larger than our Moon

Results
6 wks 80% Venus has a beautiful name and is the second
planet from the Sun. It’s terribly hot—even
Experimentation Success Rate
hotter than Mercury
Awesome Words
 A Picture Always
Reinforces The
Concept
Images reveal amounts of data, remember: use an
image instead of long texts
Tendency
80 Phase 1
Despite being red, Mars is
60 actually a cold place

40 Phase 2
Has a beautiful name and is
20 the second planet

Phase 3
If you want to modify this graph, click on it, follow the link, change Has a beautiful name and is
the data and replace it the second planet
Results

Outcome Outcome
Treatment Test 1 Test 2 Test 3 Treatment Test 1 Test 2 Test 3

Group 1 250 450 200 Group 1 400 450 57

Group 2 450 500 120 Group 2 450 520 120

Group 3 450 600 201 Group 3 240 100 400

A Picture Is
Worth A
Thousand
Words
Results Analysis
Jupiter
60% Mercury Neptune
Planet Mars is Neptune is the
a cold place farthest planet

40%

Mars

80% 50% 80% 20%

Success Rate

97% 80%
Patients Cured No Secondary Effects
4,498,300,000
Big numbers catch your audience’s attention
This Is A Map

Mercury
It’s a gas giant, composed
mostly of hydrogen and
Venus helium

Venus has a beautiful

name and is the second
planet from the Sun Neptune
Neptune is the farthest
planet from the Sun and
the fourth-largest
Desktop Software
You can replace the image on the screen
with your own work. Just delete this one,
add yours and send it to the back
Conclusions
Mercury is the closest planet to the Sun and
the smallest one in the Solar System—it’s
only a bit larger than our Moon. The
planet’s name has nothing to do with the
liquid metal since it was named after the
Roman messenger god
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Alternative Resources
Photos
● Doctor-opening-up-syringe
● Medic-man-using-microscope
● Doctor-doing-research-his-laptop
● Doctor-holding-bottle-pills
● Doctor-analyzing-with-microscope
● Crop-hands-offering-two-pills
● Microscope-clinical-laboratory
● Doctor-holding-pills-hand 2
● Doctor-holding-pills-hand
● Hands-with-red-yellow-capsules
● Medical-treatment-with-pills
● Doctors-analyzing-with-microscope
● Front-view-syringe-vaccine-bottle
● Defocused-doctor-holding-up-pill-hand
Resources
Photos
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● Doctor-analyzing-with-microscope ● Male-nurse-holding-medical-tablets
● Cheerful-black-medic-using-microscope ● Female-scientist-with-lab-equipment
● Doctor-s-hands-tending-patient ● Scientist-looking-substance-through-microscope
● Two-pills ● Hands-holding-medical-tablets
● Doctor-giving-pills ● Doctor-hand-holding-vaccine
● Cheerful-multiracial-doctors-with-test-tube ● Medical-treatment-with-pills
● Crop-hand-holding-tablet
● Front-view-doctor-with-surgical-glove
● Doctor-using-syringe-vaccine
● Blurred-doctor-showing-pill
● Medics-with-test-tube
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 JANUARY FEBRUARY MARCH APRIL MAY JUNE

PHASE 1

Task 1

Task 2

PHASE 2

Task 1

Task 2

JANUARY FEBRUARY MARCH APRIL

PHASE
1

Task 1

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