Membangun Budaya Patient Safety dalam Pelayanan Farmasi
PATIENT SAFETY
HARLINA KISDARJONO IHQN 191108 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 ALIKE Suplemen
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 Lettering Sound-a-like, Look-a-like (SALA) penyebab 25% dari medication error ChlorproMAZINE ChlorproPAMIDE HydrALAZINE HydrOXYzine PredniSONE PrednisoLONE
MACROSYSTEM
Medication Management Process Where Adverse Drug Events Originate Source: Adapted from Bates et al.; JAMA 1995;274:29-34
Data : Medication Management Process
History-Taking Obtain Medicationrelated History
Where Adverse Drug Events Originate
Document Medication History
Source: Adapted from Bates et al.; JAMA 1995;274:29-34
11%
Medication Inventory Management
Ordering Diagnostic/ Therapeutic Decisions Made
Medication Ordered
Order verified and submitted
Surveillance
Formulary, purchasing decisions
49%
Inventory management
Pharmacy Management
Incident/adver se event surveillance and reporting
Evaluate order
Administration Management
Monitor/Evaluate Response Intervene as indicated for adverse reaction/ error
Assess and document patient response to medication according to defined parameters
Document Document administration and associated information
Select medication
Prepare medication
Dispense/ distribute medication
14%
26% Administer Medication Admin. according to order and standards for drug
Select the correct drug for the correct patient
Education Educate patient regarding medication
Educate staff regarding medications
From Computerized physician order entry: costs, benefits and challenges. A case study approach. FCG 2003.
TEAMWORK Budaya patient safety
System thinking
Komitmen bersama Keterbukaan (no blame culture) Trust antar profesi Komunikasi
MEDREC SIM
SDM Apoteker Non Apt
SISTEM
PERMENKES 89 ,1 Pintu
BUDAYA
Zero Defect IFRS Apotik pelengkap MP SIM
1 MR/ Psn
Sesuai Juml TT
DEPO UDD Visite P. Info Obat Konseling, dll.
Blame free, Nonpunitive Environment
MICROSYSTEM
KEBIJAKAN 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
RANTAI PELAYANAN OBAT 1.Pabrik
5.Penerimaan Instruksi Dr
Pemesanan apotik
6.Penulisan Resep
2.Penerimaan 7.Status & Data Pasien
3.Penyimpanan di gudang Distribusi 4.Penyimpanan di R.Racik MEDICATION ERROR
10.Penyiapan obat
8. Screening Resep
9. Etiket
11Pemanggilan pasien COUNSELING OBAT
12.Penyerahan obat 13Inform/Counseling Pemahaman
Monitoring
Ketaatan
Outcome
Keterangan Screening resep : •Administrasi error •Pharmaceutical error •Clinical error HK 2002
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
Pasien Safety
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
SCREENING RESEP
ADMINISTRATION ERROR
PHARMACEUTICAL ERROR
CLINICAL ERROR
Kejelasan tulisan
Administrativ Errors/ Prescribing Errors
Kelengkapan resep Keaslian resep Kejelasan instruksi
PHARMACEUTICAL ERRORS
Dosis Bentuk sediaan
Kesesuaian ketersediaan
Cara pemberian
Stabilitas
Alergi
Adverse drug reaction
CLINICAL ERRORS
Interactions
Kesesuaian
Drug - disease
Drug - drug Lama terapi Dosis
Cr pemberian Jumlah obat Dll Hk 2003
? Tidak ada Masalah
Masalah
PERPUSTAKAAN
Ruang Pelayanan Informasi Obat
FARMASIS ‘YAN-FARMASIS PIO
FARMASIS-DOKTER
FARMASIS DOKUMENTASI
QUALITY ASSURANCE
QUALITY ASSURANCE
QUALITY CONTROL RESEP (Penanganan Koreksi Resep) Pelayanan Resep PEMERIKSAAN PERTAMA OLEH APOTEKER ‘FRONT’
R/
PENYERAHAN OBAT KE PASIEN
R/
PEMERIKSAAN KEDUA OLEH APOTEKER ‘BACK’ BETUL
R/
R/
ARSIP RESEP
R/
SALAH R/
DISKUSI ANTAR APOTEKER
KONSULTASI DOKTER
KOREKSI RESEP
KONFIRMASI PETUGAS
Menyusul ke alamat Pasien
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
ISMP Medication Safety Self Assessment for Hospitals,
Physicians Ann Intern Med. 1 Jan 2002
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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