Membangun Budaya Patient Safety dalam Pelayanan Farmasi PATIENT SAFETY HARLINA KISDARJONO IHQN BANDUNG

Transkripsi

1 Membangun Budaya Patient Safety dalam Pelayanan Farmasi PATIENT SAFETY HARLINA KISDARJONO IHQN BANDUNG

2 PATIENT SAFETY

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4 OPEN SYSTEM Microsystem (Ujung Tombak Pasien) Macrosystem (Rumah sakit) Megasystem (Nasional) Microsystem dipengaruhi bahkan tergantung kepada sistem yang lebih besar

5 MEGASYSTEM LOOK ALIKE-SOUND ALIKE LASA

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10 SOUND ALIKE Suplemen PROZA PROZAC antidepresan echinacea, vit C, Zn fluoxetine Antikolesterol LESCHOL Fluvastatin LESICHOL lecithin, vitamin Essential Phospholipids Analgetik MEFINTER METIFER mecobalamin As.mefenamat mecobalamin Antiulcer LOSEC LASIX diuretika antiemetik, antivertigo antipsikotik CHLORPROMAZIN CHLORPROPAMID Antidiabet antihistamin DIPHENHYDRAMINE DIMENHYDRINAT Antiemetik antivertigo

11 Tall Man Lettering Sound-a-like, Look-a-like (SALA) penyebab 25% dari medication error ChlorproMAZINE ChlorproPAMIDE HydrALAZINE HydrOXYzine PredniSONE PrednisoLONE

12 MACROSYSTEM

13 Medication Management Process Where Adverse Drug Events Originate Source: Adapted from Bates et al.; JAMA 1995;274:29-34

14 History-Taking Obtain Medicationrelated History Document Medication History Data : Medication Management Process Where Adverse Drug Events Originate 11% Source: Adapted from Bates et al.; JAMA 1995;274:29-34 Medication Inventory Management Diagnostic/ Therapeutic Decisions Made Ordering Medication Ordered Order verified and submitted 49% Formulary, purchasing decisions Inventory management Surveillance Pharmacy Management Incident/adver se event surveillance and reporting Evaluate order Select medication Prepare medication Dispense/ distribute medication 14% 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 Administer Medication Admin. according to order and standards for drug 26% Select the correct drug for the correct patient Educate patient regarding medication Education Educate staff regarding medications From Computerized physician order entry: costs, benefits and challenges. A case study approach. FCG 2003.

15 TEAMWORK Budaya patient safety System thinking Komitmen bersama Keterbukaan (no blame culture) Trust antar profesi Komunikasi

16 SIM MEDREC 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

17 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

18 FARMASIS

19 1.Pabrik Pemesanan apotik 2.Penerimaan 3.Penyimpanan di gudang RANTAI PELAYANAN OBAT Distribusi 4.Penyimpanan di R.Racik 5.Penerimaan Instruksi Dr 6.Penulisan Resep 7.Status & Data Pasien 8. Screening Resep MEDICATION ERROR 10.Penyiapan obat 9. Etiket COUNSELING OBAT Monitoring 11Pemanggilan pasien 12.Penyerahan obat 13Inform/Counseling Pemahaman Ketaatan Outcome Keterangan Screening resep : Administrasi error Pharmaceutical error Clinical error HK 2002

20 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

21 Rantai Pelayanan Obat Kekuatan suatu rantai sama dengan kekuatan mata rantai terlemah ERROR Pasien Safety

22 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.

23 OBAT ANTIDIABET

24 SCREENING RESEP ADMINISTRATION ERROR PHARMACEUTICAL ERROR CLINICAL ERROR

25 Kejelasan tulisan Administrativ Errors/ Prescribing Errors Kelengkapan resep Keaslian resep Kejelasan instruksi

26 PHARMACEUTICAL ERRORS Dosis Kesesuaian ketersediaan Bentuk sediaan Cara pemberian Stabilitas

27 CLINICAL ERRORS Alergi Adverse drug reaction Interactions Drug - disease Drug - drug Hk 2003 Kesesuaian Lama terapi Dosis Cr pemberian Jumlah obat Dll

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29 ? Masalah Tidak ada Masalah

30 PERPUSTAKAAN

31 Ruang Pelayanan Informasi Obat

32 FARMASIS YAN-FARMASIS PIO

33 FARMASIS-DOKTER

34 FARMASIS DOKUMENTASI

35 QUALITY ASSURANCE

36 QUALITY ASSURANCE

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38 Pelayanan Resep R/ QUALITY CONTROL RESEP (Penanganan Koreksi Resep) PEMERIKSAAN PERTAMA OLEH APOTEKER FRONT R/ PEMERIKSAAN KEDUA OLEH APOTEKER BACK PENYERAHAN OBAT KE PASIEN BETUL R/ SALAH R/ ARSIP RESEP DISKUSI ANTAR APOTEKER R/ KONSULTASI DOKTER KONFIRMASI PETUGAS Menyusul ke alamat Pasien R/ KOREKSI RESEP

39 FARMASIS FEEDBACK QA

40 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

41 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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