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Medication ErrorMedication Error

Drs. Budi Raharjo, Sp.FRS

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DefinisiDefinisi

Drug Misadventure

Adverse Drug Event

Medical Error

Potential Error

Dispensing ErrorPrescribing Error

Copliance Error, etc!.error

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DefinisiDefinisi

"ejadian #ang dapat dicegah

Pea$aian obat #g tida$ tepat shg erugi%

$an pasien

Pengobatan dala $ontrol provider&pro'esio

nal $esehatan dan as#ara$at

Dapat disebab$an oleh( Pra$te$ Pro'esional,

Penulisan Resep, Dispensing )bat, Siste,

Pea$aian )bat, dll

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Fakta Medication ErrorFakta Medication Error

*,+ pasien -on%)bstetricAdverse

Drug Event

* Cardiac Arrest$rn Medct.Error

/01.111 orang eninggal di 2S $rn

Medication Error

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Survey Medication ErrorSurvey Medication Error3/ Farasis di apoti$ setiap inggun#a teu$an 4/1

potensial error

53 Farasis di RS setiap inggun#a teu$an + 6 /1

potensial errorStudi lain(

6 37 prescription error

6 +/ prescription De'icienc#

6 7 Drug 8nteraction

6 /3 Pasien tida$ paha

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RANTAIRANTAI

PELAYANANPELAYANAN

OBATOBAT

Pabri$

Pemesanan

Apotek

Penerimaan

Penyimpanan

di Gudang

Distribusi

Pen#ipanandi Apote$

Pen#iapan )bat

Peanggilan P9

Pen#erahan:8n'o

Eti$et

Status ;

Data P9

Screening

Resep

Peneriaan

Resep

Penulisan

Resep

Medication Error

Counseling

Monitoring

Pemahaman - Kepatuhan

Screening:

-Administrative error

-Pharmaceutical error

-Clinical error

Outcome Terapi

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ERRORERROR

MA-2S8A

PERA-

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PRESCRIPTIONPRESCRIPTION

MONITORINGMONITORING

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Prescription MonitoringPrescription Monitoring

Farasis harus eili$i $opetensidala onitoring peresepan elalui

pebelajar%an ; pra$te$ penerapan

pengetahuan serta $etrapilan $lini$Pende$atan terstru$tur dala onitoring

peresepan( etode P%A%M >Problem-

Assessment/Action-Monitoring?=ujuan( to ensure the safe, effective and

rational use of medicine

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PAM-Source & NeedPAM-Source & Need

Clinical Knowledge and Skill: can be

increase b e!ercise

"ell #ocumentation

$efference $esource:

- %ational/&os'ital (hera'eutic )uideline

- Another )uideline: *%+, Martindale,

SP #rug nformation, +, nternet

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P( Proble@ to collect and inter'ret all relevant

information in order to identif actual and

'otential 'roblem: Prescri'tion related 'roblem.du'lication, legalit, stock, etc, Administrative

relative 'roblem .route, form, time, frecuenc,

com'liance, #$P, #isease 'roblem, %utritional

'roblem, etc

A( Assessent&Action@ to list and 'rioritise all

'roblems .actual 0 'otential, to liaise with

medical staff and 'atient to establish desire

outcome

M( Monitoring@ to assess the outcome of the

intervention .as a''ro'riate start PAM

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Kasus 1Kasus 1

Seorang 8bu datang $e Apote$ 288 tapa$ pani$ingin ebeli obat sa$it $epala #g paling anjur

g sa$it $epala adl suain#a. Pa$ A 3 tahun. Dia

pernah sa$it $epala beberapa $ali, tapi $ali ini #g

paling parah

Disertai ual, $a$i ; tangan $eseutan ; aga$

leas. Bapa$ A sudah peri$sa $e Dr Spesialis

8nternis pra$te$ sasta dan diberi resep ut$ + haridengan pesan ut$ $ebali $ontrol stl obat habis.

)bat sudah diinu tapi sa$it $epala belu

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