medical error 2015

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    '(U Memahami tanggung )awa* RS

    se*agai penyedia pelayanan yang

    mem+!"us"an "epada "e*utuhandan harapan pasien terhadappelayanan di RS

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    '( Dapat men)elas"an tentang

    "eselamatan pasien selama

    menerima pelayanan di RS Dapat memahami medi-al err!r di

    RS dan *agaimana -ara

    pen-egahan terhadap medi-alerr!r

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    '( -!ntinued/ Dapat memahami sistem

    mana)emen mutu, untu" men)aga

    mutu pelayanan di RS Dapat memahami )enis pelayanan

    yang ada di RS Dapat memahami, mengidenti0"asi,

    dan menganalisa peran pasiense*agai mitra dlm pelayanan"esehatan di RS

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    '! Err is 1umanKohn LT,

    Corrigan JM,Donaldson MS, Eds. To

    Err Is Human.Washington NationalPress, Wash, DC.2000.

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    Apa"ah 2Medi-ati!n Err!r34 Medication Error adalah kejadian yang

    dapat dicegah yang dapat

    menyebabkan penggunaan medikasiyang tidak tepat (inappropriate) atau

    mencelakakan pasien, pada saat

    medikasi itu dikendalikan oleh paraprofesional kesehatan, pasien, atau

    konsumer.

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    Apa"ah 2Medi-ati!n Err!r34Kejadian tersebut berhubungan dengan:

    pra"te" pr!+esi!nal

    pr!du" perawatan "esehatan

    pr!sedur and sistem

    pr!du-t la*eling, pa-"aging, andn!men-lature

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    Apa"ah 2Medi-ati!n Err!r34

    #/ dispensing

    Distri*usi

    (enyerahan administrati!n/

    edu"asi

    (emantauan m!nit!ring/

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    Apa"ah 2Medi-ati!n Err!r34 esalahan yang di*uat !leh d!"ter,

    perawat, ap!te"er, -aregi5er, atau

    pasien selama dalam pr!sesperesepan, pem*erian, penyerahanatau penggunaan !*at. (enye*a*tersering adalah nama6nama !*atyang mirip Benylin and Benadryl/"emasan, la*el dan peresepan yangmirip.

    (RE7E8'I89 MEDICA'IO8 ERRORS: A 7ital (re-auti!n ;r!m the *!!": 1!w '!9et 'he Best Medi-al Care By Dr.Aniruddha Malpani and Dr.An)ali Malpani

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    Bila in+!rmasinya seperti ini,

    apa"ah Anda mau nai" pesawat4

    xtra xtra

    Airlines expect 1-2

    jets to crash dailyebih !""" kematian#minggu

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    Bagaimana dengan men)adi pasiendalam sistem "esehatan4

    xtra xtra

    Airlines expect 1-2 jets to

    crash daily

    Over 1000 deaths expected

    weekly

    $

    Kohn et al. Committee on qalit! health "are in #meri"a. $%M. #"adem!

    xtra xtra

    Airlines expect 1-2 jets to

    crash daily

    Lebih dari 1000

    kematian/mingg

    $((,000 )'*,000

    Kematian+tah

    n ai-atmedi"al errors

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    Errorsare costlyin terms of loss

    of trustin the health care systemby patients and diminished

    satisfactionby both patients and

    health professionals

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    %ccidents!&',"

    MedicalErrors*!"","""

    %l+heimers-,'&

    iabetes

    !,'/&www!cdc! ov/nchs/"astats! Accessed #an 2012! $ased on 200% data!

    Rang"ing Medi-al Err!rsse*agai (enye*a* ematian

    0eart!,"

    1ancer2&,/2

    3troke!'2,42&

    ung

    !&,4&-

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    (enye*a* Medi-al Err!r

    5&omnikasi brk dalam tim kesehatan5'erintah verbal

    5tlisan tangan yang jelek/tidak terbaca

    5'emilihan obat yang tidak tepat

    5(edikasi yang )missing*

    5'enjadalan yang tidak tepat

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    (enye*a* Medi-al Err!r #/

    5look alike / sond alike drgs

    5poli"armasi

    5availability o" "loor stock +no second check,

    5nteraksi obat

    5hectic work environment

    5lack o" compter decision spport

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    Tie Error/ Diagnosti Err!r atau "eterlam*atan dalam

    diagn!sis.

    egagalan untu" mengguna"an u)i6u)iyang sesuai indi"asi.

    (enggunaan u)i atau terapi yangsudah "un!.

    egagalan untu" *ertinda" sesuaihasil dari u)i pemeri"saan danpemantauan.

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    Tie Error/ Treatmen Err!r dalam pela"sanaan !perasi,

    pr!sedur, atau u)i pemeri"saan.

    Err!r dalam pem*erian treatment Err!r dalam d!sis dan met!de

    penggunaan !*at eterlam*atan treatmen yang

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    Tie Error/ Preenti1 egagalan untu" menyedia"an

    treatmen pr!0la"ti"

    (emantauan atau +!ll!w6up dalamtreatmen yang inade"uat

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    Classi+ying medi-ati!n err!rs

    A circmstances exist "or potential errors to occr

    $ an error occrred bt did not reach the patient

    error reached the patient bt did not case harm

    patient monitoring re3ired to determine lack o" harm

    error cased temporary harm and some intervention

    4 temporary harm with initial or prolonged hospitali5ation

    6 error reslted in permanent patient harm

    7 error re3ired intervention to sstain the patient*s li"e

    error contribted to the patient*s death

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    More commonly, errors are

    caused by faulty systems,processes, and conditionsthat

    lead people

    to make mistakes or

    fail to prevent them.

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    Strateg! 1or$mroement

    Esta-lishing a national 1o"s to"reate leadershi, resear"h,

    tools, and roto"ols toenhan"e the no3ledge -asea-ot sa1et!.

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    Strateg! 1or$mroement

    $denti1!ing and learning 1romerrors -! deeloing a

    nation3ide -li" mandator!reorting s!stem and -!en"oraging health "are

    organi4ations and ra"titionersto deelo and arti"iate inolntar! reorting s!stems.

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    Strateg! 1or$mroement

    5aising er1orman"e standardsand e6e"tations 1or

    imroements in sa+ety thr!ughthe a-ti!ns !+ !5ersight!rganiati!ns, pr!+essi!nalgr!ups,

    and gr!up pur-hasers !+ health-are.

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    Strateg! 1or$mroement

    $mlementing sa1et! s!stemsin health "are organi4ations to

    ensre sa1e ra"ti"es at thedelier! leel

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    Health care is a decade or more

    be-hind many other high-riskindustries in its attention to

    ensuring basic safety.

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    Voluntary reporting systems will

    provide an important complementto the mandatory system.

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    The process of developing and

    adopting standards also helpsto form expectations for safety

    among providers and consumers

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    Medication errors now occur

    freuently in hospitals,yet many hospitals are not making use

    of known systems for improving

    safety!

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    "ith adeuate

    leadership,attention,

    and resources,

    improvements canbe made.