BLANKO MONITORING PELABELAN OBAT GOLONGAN HIGH ALERT

BULAN :

NO NAMA OBAT HIGH ALERT TERLABEL KETERANGAN

YA TIDAK1 APIDRA2 BLED STOP INJ3 BUNASCAN INJ4 CA GLUCONAS INJ5 CODEIN 10 MG6 CODEIN 20 MG7 D 408 DECAIN INJ9 DOPAMIN

10 EPHEDRIN11 EPHINEPHRIN12 FARSIX TAB13 FENTANYL14 FUROSEMID TAB15 KCL16 KETALAR17 LASIX INJ18 METHERGIN INJ19 METHERGIN TAB20 METHYL ERGOMETRIN TAB21 MEYLON 25 ML222324 MILOZ INJ 5 MG25 MORPHIN INJ 10 MG/ML26 MST CONT 10 MG27 NA PHENITHOIN INJ28 OTSU SALIN 3%29 PETIDIN INJ30 PITOGIN INJ31 SAFOL INJ32 STESOLID INJ,33 STESOLID RT34 STESOLID SYR35 VALISANBE 2 MG36 VALISANBE 5 MG37 VASCON INJ

TOTAL 0 0 0

Perhitungan PERSENTASE HIGH ALERT : TOTAL OBAT YANG TIDAK TERLABELI

JUMLAH PEMAKAI

AN

MGSO4 20%MGSO4 40%

TOTAL OBAT HIGH ALERT YANG KELUAR

X 100 %

TOTAL OBAT HIGH ALERT YANG KELUAR

BLANKO MONITORING PELABELAN OBAT GOLONGAN LASA (LOOK ALIKE SOUND ALIKE )

BULAN :

NO NAMA OBAT HIGH ALERT TERLABEL KETERANGAN

YA TIDAK123456789

10111213141516171819202122232425 epHEDRIN inj26 epHINEPRIN inj2728293031 Glucovance 2,5/ 5003233343536373839404142

JUMLAH PEMAKAI

AN

Actalipid 10 mgActalipid 20 mgAlganax 0,5 mgAlganax 1 mgAmlodipin 10 MGAmlodipin 5 MGAmoxsan 250Amoxsan 500Amoxsan DROPAmoxsan DSBiothicol DSBiothicol F DScalsivas 10 mg calsivas 5 mgceFADROXIL 500ceFAT 500cefOTAXIMcefTRIAXONClaneksi DSClaneksi F DSCodein 10 MGCodein 20 MGDumin rt 125 MGDumin rt 250 MG

Flurin DMP SYRFlurin SYRGlucophage XR 500Glucophage XR 750

Glucovance 5/500KAEN 4AKAEN 4BMagnesium sulfat 20%Magnesium sulfat 40 % Nucholin inj 250 MGNucholin inj 500 MGOndancetron INJPraxion F SYR Praxion SYRRanitidin INJ

43444546474849505152535455565758

TOTAL 0 0 0

Perhitungan PERSENTASE LASA : TOTAL OBAT YANG TIDAK TERLABELI TOTAL OBAT LASA YANG KELUAR

Salbutamol 2 MGSalbutamol 4 MGSanmol SYRSanmol CHEWSanmol DROPSanmol TAB Santa E 200 IUSanta E 400 IUTensiphar 5 MG Tensiphar 10 MGTrovensis inj 4 MGTrovensis inj 8 MGwida D5 1/2 NSwida D5 1/4 NSwida NSwida RL

BLANKO MONITORING PELABELAN OBAT GOLONGAN LASA (LOOK ALIKE SOUND ALIKE )

X 100 %

BLANKO MONITORING PELABELAN OBAT GOLONGAN HIGH ALERTbulan :NO NAMA OBAT 1 2 3 4 5 6 7 8 9 10 11 12 13 14

YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA

1 APIDRA2 BLED STOP INJ3 BUNASCAN INJ4 CA GLUCONAS INJ5 CODEIN 10 MG6 CODEIN 20 MG7 D 408 DECAIN INJ9 DOPAMIN

10 EPHEDRIN11 EPHINEPHRIN12 FARSIX TAB13 FENTANYL14 FUROSEMID TAB15 KCL16 KETALAR17 LASIX INJ18 METHERGIN INJ19 METHERGIN TAB20 METHYL ERGOMETRIN TAB21 MEYLON 25 ML222324 MILOZ INJ 5 MG25 MORPHIN INJ 10 MG/ML26 MST CONT 10 MG27 NA PHENITHOIN INJ28 OTSU SALIN 3%

MGSO4 20%MGSO4 40%

29 PETIDIN INJ

BLANKO MONITORING PELABELAN OBAT GOLONGAN HIGH ALERTNO NAMA OBAT 17 18 19 20 21 22 23 24 25 26 27 28 29 30

YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA1 APIDRA2 BLED STOP INJ3 BUNASCAN INJ4 CA GLUCONAS INJ5 CODEIN 10 MG6 CODEIN 20 MG7 D 408 DECAIN INJ9 DOPAMIN

10 EPHEDRIN11 EPHINEPHRIN12 FARSIX TAB13 FENTANYL14 FUROSEMID TAB15 KCL16 KETALAR17 LASIX INJ18 METHERGIN INJ19 METHERGIN TAB20 METHYL ERGOMETRIN TAB21 MEYLON 25 ML222324 MILOZ INJ 5 MG25 MORPHIN INJ 10 MG/ML26 MST Cont27 NA PHENITHOIN INJ28 OTSU SALIN 3%

MGSO4 20%MGSO4 40%

29 PETIDIN INJ

BLANKO MONITORING PELABELAN OBAT GOLONGAN HIGH ALERTNO NAMA OBAT 1 2 3 4 5 6 7 8 9 10 11 12 13 14

YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA30 PITOGIN INJ31 SAFOL INJ32 STESOLID INJ,33 STESOLID RT34 STESOLID SYR35 VALISANBE 2 MG36 VALISANBE 5 MG37 VASCON INJ

BLANKO MONITORING PELABELAN OBAT GOLONGAN HIGH ALERTNO NAMA OBAT 17 18 19 20 21 22 23 24 25 26 27 28 29 30

YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA30 PITOGIN INJ31 SAFOL INJ32 STESOLID INJ,33 STESOLID RT34 STESOLID SYR35 VALISANBE 2 MG36 VALISANBE 5 MG

37 VASCON INJ

CATATAN : CARA PENGISIAN :1. PERHITUNGAN DITULIS MENGGUNAKAN BENTUK DIAGRAM LIDI PADA TANGGAL AUDIT2. DIAGRAM LIDI DITOTAL PADA AKHIR TANGGAL YANG TERCANTUM DITABEL3. TOTAL JUMLAH DITULIS MENGGUNAKAN ANGKA 4 DIKUMPULKAN SELAMBAT LAMBATNYA TANGGAL 3 BULAN BERIKUTNYA

14 15 16 TOTAL TDK YA TDK YA TDK YA TDK

0 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 0

0 0

30 TOTALTDK YA TDK

0 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 0

0 0

14 15 16 TOTALTDK YA TDK YA TDK YA TDK

0 00 00 00 00 00 00 00 0

30 31 TOTALTDK YA TDK YA TDK

0 00 00 00 00 00 00 0

0 0

BLANKO MONITORING PELABELAN OBAT GOLONGAN LASABULAN :NO NAMA OBAT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA1 Actalipid 10 mg2 Actalipid 20 mg3 Alganax 0,5 mg4 Alganax 1 mg5 Amlodipin 10 MG6 Amlodipin 5 MG7 Amoxsan 2508 Amoxsan 5009 Amoxsan DROP

10 Amoxsan DS11 Biothicol DS12 Biothicol F DS13 calsivas 10 mg 14 calsivas 5 mg15 ceFADROXIL 50016 ceFAT 50017 cefOTAXIM18 cefTRIAXON19 Claneksi DS20 Claneksi F DS21 Codein 10 MG22 Codein 20 MG23 Dumin rt 125 MG24 Dumin rt 250 MG25 epHEDRIN inj26 epHINEPRIN inj27 Flurin DMP SYR28 Flurin SYR29 Glucophage XR 500

30 Glucophage XR 750

BLANKO MONITORING PELABELAN OBAT GOLONGAN LASABULAN :NO NAMA OBAT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA31 Glucovance 2,5/ 50032 Glucovance 5/50033 KAEN 4A34 KAEN 4B35 Magnesium sulfat 20%36 Magnesium sulfat 40 % 37 Nucholin inj 250 MG38 Nucholin inj 500 MG39 Ondancetron INJ40 Praxion F SYR 41 Praxion SYR42 Ranitidin INJ43 Salbutamol 2 MG44 Salbutamol 4 MG45 Sanmol SYR46 Sanmol CHEW47 Sanmol DROP48 Sanmol TAB 49 Santa E 200 IU50 Santa E 400 IU51 tensiphar 5 MG 52 tensiphar 10 MG53 trovensis inj 4 MG54 trovensis inj 8 MG55 wida D5 1/2 NS56 wida D5 1/4 NS57 wida NS

58 wida RL

BLANKO MONITORING PELABELAN OBAT GOLONGAN LASABULAN :NO NAMA OBAT 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA1 Actalipid 10 mg2 Actalipid 20 mg3 Alganax 0,5 mg4 Alganax 1 mg5 Amlodipin 10 MG6 Amlodipin 5 MG7 Amoxsan 2508 Amoxsan 5009 Amoxsan DROP

10 Amoxsan DS11 Biothicol DS12 Biothicol F DS13 calsivas 10 mg 14 calsivas 5 mg15 ceFADROXIL 50016 ceFAT 50017 cefOTAXIM18 cefTRIAXON19 Claneksi DS20 Claneksi F DS21 Codein 10 MG22 Codein 20 MG23 Dumin rt 125 MG24 Dumin rt 250 MG25 epHEDRIN inj

BLANKO MONITORING PELABELAN OBAT GOLONGAN LASABULAN :NO NAMA OBAT 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA26 epHINEPRIN inj27 Flurin DMP SYR28 Flurin SYR29 Glucophage XR 50030 Glucophage XR 75031 Glucovance 2,5/ 50032 Glucovance 5/50033 KAEN 4A34 KAEN 4B35 Magnesium sulfat 20%36 Magnesium sulfat 40 % 37 Nucholin inj 250 MG38 Nucholin inj 500 MG39 Ondancetron INJ40 Praxion F SYR 41 Praxion SYR42 Ranitidin INJ43 Salbutamol 2 MG44 Salbutamol 4 MG45 Sanmol SYR46 Sanmol CHEW47 Sanmol DROP48 Sanmol TAB 49 Santa E 200 IU50 Santa E 400 IU51 tensiphar 5 MG

52 tensiphar 10 MG53 trovensis inj 4 MG54 trovensis inj 8 MG55 wida D5 1/2 NS

BLANKO MONITORING PELABELAN OBAT GOLONGAN LASABULAN :NO NAMA OBAT 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA TDK YA56 wida D5 1/4 NS57 wida NS58 wida RL

CATATAN : CARA PENGISIAN :1. PERHITUNGAN DITULIS MENGGUNAKAN BENTUK DIAGRAM LIDI PADA TANGGAL AUDIT2. DIAGRAM LIDI DITOTAL PADA AKHIR TANGGAL YANG TERCANTUM DITABEL3. TOTAL JUMLAH DITULIS MENGGUNAKAN ANGKA 4 DIKUMPULKAN SELAMBAT LAMBATNYA TANGGAL 3 BULAN BERIKUTNYA

15 TOTAL TDK YA TDK

0 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 0

0 0

15 TOTAL TDK YA TDK

0 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 0

0 0

30 31 TOTAL TDK YA TDK YA TDK

0 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 0

30 TOTALTDK YA TDK

0 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 00 0

0 00 00 00 0

30 TOTALTDK YA TDK

0 00 00 0

HIGH ALERTLASAmonitoring harian hamonitoring harian lasa