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MEDICATION SAFETY DI OK DAN ICU
AA Raka KarsanaBali International Convention Centre, Nusa Dua – Bali, 10-12 Juli 2019
Sesungguhnyaseperti apakahsituasi di OK?
BEDANYA DG RUANGAN LAIN
NYARIS TIDAK ADA DOUBLE CHECK
PENGGUNAAN OBAT DI OK
ERROR RATE
Nanji KC, Patel A, Shaikh S, Seger DL, Bates DW. Evaluation of perioperative medication errors and adverse drug events. Anesthesiology 2016; 124:25–34
127 dari 277 Pembedahan
1 dari 2.2 Pembedahan
79.3% = Preventable
Atau
Apa saja errors yg sering...?
salah dosis (kalkulasi), konsentrasi, kec infus;
Substitusi/salah identfikasi (syringe atau ampule/vial swap);
repetisi (extra dose) dan omission (missed dose).
Salah rute,
Salah programming pd infusion pumps,
Memberikan obat yg diketahui alergi,
Salah flushing line stlh pemberian obat,
…………..?.
Sisabupivacaine &
Neost+Glikopirolat disimpan
di saku
P 58, Cangkok bypass arteri aortoiliac, epidural analgesia post-op
Bupivacaine 12 mLDlm Syringe X mL, 4mL diinjeksikan
8Ml Komb Neost +Glikopirolat dlmsyringe X mL
Sisabupivacaine &
Neost+Glikopirolat disimpan
di saku
Pd akhir op, Neuromus-
cular blockade Reserve: 6 mL
Pasientetap
LEMAH, hrs inj lg
BARU DisadariSALAH OBAT –vol obat
tetap 8mL
ISMP: Key Medication Errors in the Surgical Environment, Apeil 13, 2016
Medication error Di OK
W 68 th, TKR
Plan : As Tranexamat inj
unt bleeding risk; bupivacaine-pain
management
MaksudnyaEpidural
Analgesia dg BUPIVACAINE
AS TRANEXAMAT diinjeksikan
INTRATHECALL
PS KEJANG Ekstremitas
Bawah+ fenitoin. VT
ISMP: Key Medication Errors in the Surgical Environment, Apeil 13, 2016
ICU,; Rehabilitasi
fisik
“There has been a terrible mistake.” This is what the parents were told after it was discovered that epinephrine (adrenaline) instead of lidocaine(Xylocaine™) was found to be in the syringe that had been used to locally infiltrate the ear of a seven year old boy.
The incident led to a cardiac arrest and death of the child.
2010
STRATEGI MEDICATION SAFETY DI OK
STRATEGI MEDICATION SAFETY DI OK
Medication reconciliation
Time out: Allergies, antibiotic given, etc.
Protocols dan kelengkapan untuk malignant hyperthermia, cardiac arrest dll.
Drug trays in anaesthesia carts:
Terstandard, label jelas.
Manajemen high risk/dangerous drugs
No conc. drugs , satu konsentrasi obat di cart/OK
Label
Multidose vial, perlu
PENGAWET
BENZYL ALCH :
LEMAH OTOT KAKI
The International Spine Intervention Society’s Patient Safety Committee
PHENOL & FORMALIN : DISORIENTA
SI
MET & PROPYL PARABEN: CHRONIC ADHESIVE
ARACHOIDITIS
STRATEGI MEDICATION SAFETY DI OK
Regional anaesthetic solutions dipisah dari obat i.v.
Tiap obat diberi label dg nama, tgl, konsentrasi
Unlabeled syringe segera dikeluarkan
Verifikasi high risk med dan weight based doses oleh 2 orang
Teknik Aseptis
Baca dan verifikasi setiap label vial, ampul, syringe sebelum pemberian :
Sistem barcode digunakan dengan isyarat suara dan visual
STRATEGI MEDICATION SAFETY DI OK
Smart pump digunakan untuk semua infus; distandarisasi di seluruh unit; memiliki “drug libraries dg guardrails dan alerts” –menghindari kelebihan dosis 10-100 kali lipat -insulin, heparin, propofol, dan vasoactive medications
Ohashi K, Dalleur O, Dykes PC, Bates DW. Benefits and risks of using smart pumps to reduce medication error rates: a systematicreview.DrugSafety2014;37:1011–2
Identifikasi dg jelas pemberian:
Administration sets untuk rute khusus (epidural, i.v., etc.); Kode warna (kuning = epidural, merah = arterial);
STRATEGI MEDICATION SAFETY DI OK
Colour-Coding to Indicate Route of Administration
Hanya 1 obat masuk sterile field,
Jika ada obat tanpa label- “discarded”
Segregasi cairan topical atau irigasi dari sedparenteral.
Non-punitive QA system untuk pelaporan, analysis, dan intervensi insiden
Kebijakan tertulis untuk medication safety; teaching ttg kebijakan tsb untuk staf baru
Supervisi, TEACHING dan pelatihan Yang memadai
STRATEGI MEDICATION SAFETY DI OK
Membangun budaya menghargai dan kolaborasi yang mendukung keselamatan pasien dan membangun kepatuhan
DR MAHIBAN THOMASMaxillofacial and oral surgeon,
Royal Darwin Hospital.
Ada Apoteker yg ditugaskan di OK;
Apoteker berpartisipasi dlm pendidikan;
Apoteker OK mendapat pendidikan khusus(specialized education)
Obat baru?
Unique i.v. solutions (glucose, heparin, hypertonic, sterile water, epidural solutions) disimpan terpisah dg regular i.v. solutions
STRATEGI MEDICATION SAFETY DI OK
Consensus Recommendations for Improving Medication Safety in the Operating Room
MEDICATION SAFETY DI ICU
Latar belakang
TERAPI OBAT DI ICU
STRESSFUL
COMPLEX
CHANGING
BANYAK PPA
PS KRITIS
The greatest risk of error Multicentered studies (Ridley and colleagues
and Calabrese and colleagues)
Faktor Risiko medication errors di intensive care unit
Medication Reconciliation
NSAIDs
• HTN
Amlodipin
• Ankle Edema
Furosemide
• Nausea
Metoklopramid
• Movement disorder
Levodopa
Drip fentanyl IV tdk
distop: Ileus
memburuk
Tonic-clonic seizures
selama terapi imipenem
pseudomonal pneumonia
Contoh strategi untuk mencegahmedication errors
Optimalisasi medication process
1. Standarisasi obat – Formularium, CP/PPK
2. Computerized physician order entry dan clinical decision support
3. Bar code technology & RFID
4. Computerized intravenous infusion devices
5. Medication reconciliation
MEDICATION RECONCILIATION
MTEs = Medication transfer errors
Menghilangkan faktor risiko situasional
1. Hindari jam kerja yang berurutan dan kumulatif yang berlebihan
2. Minimalkan interupsi dan distraksi
3. Supervisi trainee
Contoh strategi untuk mencegahmedication errors
Mencegah kelalaian dan error
1. Intensivist participation in ICU care
2. Adequate staffing
3. Pharmacist participation in ICU care
4. Incorporation of quality assurance into academic education
Contoh strategi untuk mencegahmedication errors
Peran PPA
Intensivist di ICU menurunkan medication errors dari 22% sampai 70%, komplikasi sampai 50%, ICU mortality, ICU length of stay, dan hospital length of stay serta meningkatkan patient safety.
Apoteker, berperan penting dlm medication safety di ICU. Sediaan IV diprepare di IF oleh Apoteker dg proses
terstandar dan kons obat terstandar. Meningkatkan patient safety dg menurunkan
preventable ADEs 66% sekaligus memperpendekLOS, menurunkan mortality, dan menurunkan biayaobat
………………………
Pharmacist participation in ICU care
Patient history Pain score &
management
Switching drug/dosage
form/Stop
Antimikrobadan marker
infeksi
Dose adjustment
Drug interaction &
incompatibility
Usulpemeriksaan
penunjang………?
Pharmacist Participation in ICU Care
Take Home Messagges
OK dan ICU merupakan unit kerja dengansituasi High Risk.
Ada beberapa Risk Factors yg dapatmenimbulkan MEDICATION INCIDENT di OK dan ICU.
Banyak best practices yang terbukti dapatmeningkatkan MEDICATION SAFETY di OK dan ICU, termasuk OTOMATISASI.
APOTEKER dapat memberi kontribusisignifikan dalam mewujudkan MEDICATION SAFETY di OK dan ICU.
TERIMA KASIH