Membangun Budaya Patient Safety dalam Pelayanan Farmasi

PATIENT SAFETY

HARLINA KISDARJONOIHQN191108

BANDUNG

PATIENT SAFETY

OPEN SYSTEM

Microsystem (Ujung Tombak Pasien)

Macrosystem (Rumah sakit)

Megasystem (Nasional)

Microsystem dipengaruhi bahkan tergantung kepada sistem yang lebih besar

MEGASYSTEM

LOOK ALIKE-SOUND ALIKE

LASA

SOUND ALIKESuplemen PROZA

echinacea, vit C, Zn

PROZAC

fluoxetine

antidepresan

Antikolesterol LESCHOL

Fluvastatin

LESICHOL

lecithin, vitamin

Essential Phospholipids

Analgetik MEFINTER

As.mefenamat

METIFER

mecobalamin

mecobalamin

Antiulcer LOSEC LASIX diuretika

antiemetik, antivertigo

antipsikotik

CHLORPROMAZIN CHLORPROPAMID Antidiabet

antihistamin DIPHENHYDRAMINE DIMENHYDRINAT Antiemetik antivertigo

Tall Man LetteringSound-a-like, Look-a-like (SALA)

penyebab 25% dari medication error

ChlorproMAZINE

ChlorproPAMIDE

HydrALAZINE

HydrOXYzine

PredniSONE

PrednisoLONE

MACROSYSTEM

Medication Management ProcessWhere Adverse Drug Events

Originate

Source: Adapted from Bates et al.; JAMA 1995;274:29-34

Pharmacy Management

Ordering

Data : Medication Management ProcessWhere Adverse Drug Events Originate

Source: Adapted from Bates et al.; JAMA 1995;274:29-34

Dispense/distribute

medication

Evaluate order

Select medication

Order

verified

and

submitted

Prepare medication

History-Taking

EducationAdminister MedicationDocument

Medication Inventory Management

Administration Management

Surveillance

49%

From Computerized physician order entry: costs, benefits and challenges. A case study approach. FCG 2003.

Monitor/Evaluate Response

Document

Medication

History

Obtain

Medication-

related

History

Diagnostic/

Therapeutic

Decisions

Made

Medication

Ordered

Inventory

management

Formulary,

purchasing

decisions

Incident/adverse event

surveillance

and reporting

Intervene asindicated for

adverse

reaction/error

Assess and document

patient response

to medicationaccording to

defined parameters

Documentadministrationand associated

information

Admin.

according to

order and

standards

for

drug

Select the

correct drug

for

the correct

patient

Educate

patient

regarding

medication

Educate staff

regarding

medications

11%

14%

26%

TEAMWORK

Budaya patient safety

System thinking Komitmen bersama

Keterbukaan (no blame culture)

Trust antar profesi

Komunikasi

Zero Defect

PERMENKES

89 ,1 Pintu

MEDRECSDM

ApotekerNon Apt

SISTEM

BUDAYA

IFRS Apotik

pelengkap

SIM

MP SIM1 MR/

Psn

Sesuai Juml TT

DEPOUDDVisite

P. Info ObatKonseling, dll.

Blame free,

NonpunitiveEnvironment

MICROSYSTEMKEBIJAKAN PELAYANAN FARMASI

Disetiap depo ada Apoteker yang bertanggung jawab

Jumlah Apt & AA sesuai dengan ratio resep, kesulitan, jumlah item obat

Pengendalian dilakukan selama pelayanan & setelah pelayanan dng penerapan konsep Pharmaceutical Care-Patient Focus

Setiap langkah pelayanan ada SOP nya

FARMASIS

1.Pabrik

10.Penyiapan obat

Distribusi 4.Penyimpanan

di R.Racik

3.Penyimpanan

di gudang

Pemesanan

apotik

2.Penerimaan

6.Penulisan Resep

5.Penerimaan Instruksi Dr

11Pemanggilan pasien

12.Penyerahan obat

Pemahaman Ketaatan

RANTAI PELAYANAN OBAT

8. Screening Resep

7.Status & Data

Pasien

9. Etiket

HK 2002

13Inform/Counseling

MEDICATION ERROR

COUNSELING OBAT

Keterangan

Screening resep :

•Administrasi error

•Pharmaceutical error

•Clinical error

OutcomeMonitoring

Pasien

Safety

Rantai Pelayanan Obat 1. Pabrik

2. Penerimaan Obat

3. Penyimpanan di Gudang

4. Penyimpanan di R. Racik

5. Penerimaan Resep/Instruksi Dr

6. Penulisan Resep

7. Status dan Data Pasien

8. Screening Resep

9. Etiket

10. Penyiapan Obat

11. Pemanggilan Pasien

12. Penyerahan Obat

13. Informasi dan Konseling

Pasien

Safety

Rantai Pelayanan Obat

Kekuatan suatu rantai

sama dengan kekuatan

mata rantai terlemah

ERROR

HIGH-ALERT MEDICATIONS

Contoh:

OBAT ANTIDIABETES oral

- Banyak interaksi (warfarin, digoxin, obat tiroid, beta blocker) hipoglikemi

- Bila tidak dilakukan perubahan doses bila pasien diet, exercise hipoglikemi

- Bila keliru diberikan pada pasien non diabet hipoglikemi koma.

OBAT ANTIDIABET

CLINICAL ERROR

ADMINISTRATION ERROR

PHARMACEUTICAL ERROR

SCREENING RESEP

Administrativ Errors/

Prescribing Errors

Kejelasan instruksi

Kejelasan tulisan

Kelengkapan resep

Keaslian resep

PHARMACEUTICAL ERRORS

Stabilitas

Cara pemberian

Bentuk sediaan

Dosis

Kesesuaian ketersediaan

CLINICAL ERRORS

Alergi

Adverse drug reaction

Kesesuaian

Interactions

Dll

Jumlah obat

Cr pemberian

Dosis

Lama terapi

Drug - drug

Drug - disease

Hk 2003

? Masalah

Tidak ada Masalah

PERPUSTAKAAN

Ruang Pelayanan Informasi Obat

FARMASIS ‘YAN-FARMASIS PIO

FARMASIS-DOKTER

FARMASIS DOKUMENTASI

QUALITY ASSURANCE

QUALITY ASSURANCE

PEMERIKSAAN KEDUA

OLEH APOTEKER ‘BACK’

BETUL

ARSIP

RESEP

DISKUSI ANTAR

APOTEKER

KONSULTASI

DOKTER

KONFIRMASI

PETUGAS

KOREKSI RESEP

SALAH

PEMERIKSAAN PERTAMA

OLEH APOTEKER ‘FRONT’PENYERAHAN OBAT KE

PASIEN

Menyusul

ke alamat

Pasien

QUALITY CONTROL RESEP

(Penanganan Koreksi Resep)

Pelayanan

Resep

R/

R/

R/

R/R/

R/

FARMASIS FEEDBACK QA

ANTARA TEKNOLOGI DAN BUDAYA

Budaya Pharmaceutical Care Blame free, non punitive environment Leadership Komitment

Pemanfaatan IT Sistim pencatatan dalam pelayanan Etiket rangkap Analisa Program pencatatan Medication Error Dokumentasi

PUSTAKA Pharmacist Scope of Practice, American College of

Physicians Ann Intern Med. 1 Jan 2002

ISMP Medication Safety Self Assessment for Hospitals, Institute for Safe Medication Practices, 2004

Leadership Guide to Patient Safety , Health Institute for Healthcare Improvement, 2006

Strand LM, Morley PC, Cipolle RJ. Pharmaceutical Care an Introduction, the Up John company 1992

Strand LM, Morley PC, Cipolle RJ. Pharmaceutical Care Practice, the McGraw-Hill company 1998

Cohen MR, Medication Error, American Pharmaceutical Association Foundation 2000

Bates etal, Incidence Of Adverse Drug Events & Potensial Drug Events, JAMA 1995; 274:29-34

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