Kode Dokumen: SKP-14/016/2015

KOMITE MUTU DAN KESELAMATAN RUMAH SAKIT

RSUD LASINRANG KABUPATEN PINRANG
LAPORAN INSIDEN INTERNAL
LAMPIRAN KHUSUS : RINCIAN INSIDEN KESALAHAN PEMBERIAN OBAT
(Medication Error).
1. Tanggal : Waktu Insiden Jam : .......................................................................
2. Insiden : ............................................................................................................................................
3. Kronologis Insiden : (Diisi ringkasan insiden mulai saat sebelum kejadian sampai terjadinya
insiden, Kronologis harus sesuai kejadian yang sebenarnya, bukan pendapat/asumsi pelapor:
...........................................................................................................................................................
...........................................................................................................................................................
4. Skrining resep :
a. Pemeriksaan kelengkapan administrasi resep, yaitu :
- Nama dokter : .......................................................................................................................
- Nomor Surat Izin Praktik (SIP): ............................................................................................
- Paraf / tanda tangan dokter: .................................................................................................
- Tanggal penulisan resep: .....................................................................................................
- Nama obat: ...........................................................................................................................
- Jumlah obat: .........................................................................................................................
- Aturan pakai: ........................................................................................................................
- Nama: ...................................................................................................................................
- Umur: ....................................................................................................................................
- Berat badan: .........................................................................................................................
- Jenis kelamin: .......................................................................................................................
- Alamat / nomor telpon pasien: .............................................................................................
b. Pemeriksaan kesesuaian farmaseutik, yaitu:
- Bentuk sediaan: ....................................................................................................................
- Dosis: ....................................................................................................................................
- Potensi: .................................................................................................................................
- Inkompatibilitas: ....................................................................................................................
- Cara dan lama penggunaan obat: .......................................................................................
c. Pertimbangan klinik seperti:
- Kesesuaian indikasi: .............................................................................................................
- Alergi: ....................................................................................................................................
- Efek samping: .......................................................................................................................
- Interaksi: ...............................................................................................................................
- Kesesuaian dosis: ................................................................................................................
d. Konsultasikan dengan dokter apabila ditemukan keraguan pada resep atau obatnya tidak
tersedia: Ya / Tidak *
5. Faktor faktor yang mempengaruhi kesalahan pemberian obat:
a. Faktor insiden akibat obat:
- Salah obat .............................................................................................................................
- Salah dosis ...........................................................................................................................
- Salah label ............................................................................................................................
- Salah orang ..........................................................................................................................
- Salah rute / cara pemberian .................................................................................................
- Pemberian obat yang sebenarnya kontraindikasi ................................................................
- Reaksi obat yang tidak diharapkan / Alergi .........................................................................
- Isilah informasi cara pemberian / nama obat yang diberikan ..............................................
b. Faktor proses medikasi (Medication process):
- Peresepan obat ....................................................................................................................
- Persiapan / Peracikan obat ..................................................................................................
- Pemberian obat ....................................................................................................................
- Monitoring pemberian obat ..................................................................................................
- Kualitas dan penyimpanan obat ...........................................................................................
6. Kemungkinan penyebab kesalahan pemberian obat: .....................................................................
* Coret yang tidak perlu

Investigator : ..................................................Tanda tangan : ......................................................