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Medication Error: I Wayan M. Santika, S.Farm., M.Si., Apt

This document discusses medication errors, including types of errors and factors that contribute to errors. It also provides strategies for preventing errors and monitoring for errors. The key points are: - Medication errors can be prescribing errors, transcribing errors, dispensing errors, or administration errors. - Factors that contribute to errors include poor handwriting, misunderstandings, and faulty systems. - Ways to prevent errors include accepting that errors will occur, redesigning systems to minimize human error, focusing on systems rather than individuals, promoting a culture of reporting, and analyzing reported errors. - Methods for monitoring errors include tracking high alert medications, allowing anonymous self-reporting of errors, using critical incident

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40 views

Medication Error: I Wayan M. Santika, S.Farm., M.Si., Apt

This document discusses medication errors, including types of errors and factors that contribute to errors. It also provides strategies for preventing errors and monitoring for errors. The key points are: - Medication errors can be prescribing errors, transcribing errors, dispensing errors, or administration errors. - Factors that contribute to errors include poor handwriting, misunderstandings, and faulty systems. - Ways to prevent errors include accepting that errors will occur, redesigning systems to minimize human error, focusing on systems rather than individuals, promoting a culture of reporting, and analyzing reported errors. - Methods for monitoring errors include tracking high alert medications, allowing anonymous self-reporting of errors, using critical incident

Uploaded by

Ngakan Rebell
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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MEDICATION ERROR I Wayan M. Santika, S.Farm.

,
M.Si., Apt
OVERVIEW MATERI
Medication errors, adverse drug events & adverse drug
reactions

Types of Medications Errors

Factor That Contribute to Medication Errors.

Prevent Medication Errors

Monitoring & Managing Medication Errors


AN ERROR :
“THERE IS NO SUCH THING LIKE PEOPLE ERROR, THERE IS ONLY SYSTEM ERROR”

ERROR
MEDICATION ERROR : HOW OFTEN?
MEDICATION ERROR : WELL, WAIT TILL YOU SEE WHAT
IT COST….
MEDICATION ERRORS, ADVERSE DRUG EVENTS &
ADVERSE DRUG REACTIONS

Adverse Drug Events (ADEs) Segala jenis cedera yang


disebabkan oleh pemakaian obat meliputi efek
samping obat, interaksi obat, reaksi alergi atau
kesalahan pengobatan

Adverse Drug Reactions (ADRs) Segala jenis


kejadiaan yang tidak preventable, tidak terduga,
tidak diinginkan dan respon berlebihan pada
pengobatan.

MEDICATION ERROR Segala kejadian yang


preventable yang dapat menyebabkan pengunaan
obat yang kurang tepat atau membahayakan pasien.
Types of Medications Errors
PRESCRIBING ERROR TRANSCRIBING ERROR

1. Pemilihan obat yang kurang tepat 1. Kesulitan pembacaan resep


berdasarkan indikasi,
kontraindikasi, riwayat alergi atau 2. Tidak mengerti istilah peresepan
riwayat pengobatan pasien) 3. Tanda pemakaian yang kurang
2. Dosis atau Bentuk Sediaan lengkap
3. Rute Pemberian (Analoral)
4. Kecepatan pemberian (infus)
DISPENSING ERROR ADMINISTRATION ERROR
1. Kesalahan perhitungan dosis 1. Pemakaian obat diluar jadwal
2. Dosis terbagiUnderdose 2. Pemakaian obat overdose/underdose
3. Dosis tidak terbagiOverdose 3. Pemberian dosis ganda pada pasien
dalam selang waktu tertentu
4. Kesalahan pemakaian obat
Prevent Medication Errors
1. Accept that errors will occur; slips, lapses and mistakes will happen.
2. Redesign the system.
3. Focus on the system, not the people.
4. Everyone is involved in safety (individual practitioners & organizational leadership).
5. Make the medication errors visible.
6. Minimize the consequence of medication errors.
7. Report, analyze and share medication error incidents.
8. Promote a Culture– in reporting medication errors.
A NEW WAY OF THINKING IN
MEDICATION SAFETY:
Monitoring Medication Errors
“Medication errors should be identified and documented and their causes studied in order to develop
systems that minimize recurrence.”
BEBERAPA CARA MONITORING MEDICATION ERROR :
1. HIGH ALERT MEDICATIONepinefrin, propranolol, digoxin, cairan dialysis, obat kemoterapi,
antidiabetika oral, agen sedative, opioid, muscle relaxant
2. ANONYMUS SELF REPORTSistem yang memungkinkan individu pelaku error melaporkan kejadian
secara anonymous.
3. CRITICAL INCIDENT TECHNIQUEPelatihan pelatiha kondisi kegawat daruratan pada semua
personel tenaga kesehatan
4. DISGUSED OBSERVATION AUDIT Observasi internal/eksternal mengenai medication error

5. ANY TECHNIQUE THAT YOU HAVE KNOWN :……………


VALAR DOHAERIS

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