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Salah rute,
…………..?.
P 58, Cangkok bypass arteri
aortoiliac, epidural analgesia post-op
Sisa
Bupivacaine 12 mL 8Ml Komb Neost +
bupivacaine &
Dlm Syringe X mL, Glikopirolat dlm
4mL diinjeksikan Neost+Glikopir syringe X mL
olat disimpan
di saku
BARU
Pd akhir op, Disadari
Pasien SALAH
Neuromus-
tetap OBAT –
cular blockade vol obat
LEMAH,
Reserve: 6 mL hrs inj lg tetap 8mL
ISMP: Key Medication Errors in the Surgical Environment, Apeil 13, 2016
Medication error Di OK
W 68 th, Plan : As
TKR Tranexamat inj
unt bleeding risk;
bupivacaine-pain
management
ICU,;
Rehabilitasi
fisik
Maksudnya
Epidural
PS KEJANG Analgesia dg
Ekstremitas BUPIVACAINE
Bawah AS TRANEXAMAT
+ fenitoin. VT diinjeksikan
INTRATHECALL
ISMP: Key Medication Errors in the Surgical Environment, Apeil 13, 2016
“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 PHENOL &
PENGAWET FORMALIN :
DISORIENTA
SI
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
STRATEGI MEDICATION SAFETY DI OK
Identifikasi dg jelas pemberian:
Administration sets untuk rute khusus (epidural,
i.v., etc.); Kode warna (kuning = epidural, merah =
arterial);
Colour-Coding to Indicate Route of Administration
STRATEGI MEDICATION SAFETY DI OK
Hanya 1 obat masuk sterile field,
Jika ada obat tanpa label- “discarded”
Segregasi cairan topical atau irigasi dari sed
parenteral.
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
Membangun budaya menghargai dan
kolaborasi yang mendukung
keselamatan pasien dan membangun
kepatuhan
DR MAHIBAN THOMAS
Maxillofacial and oral surgeon,
Royal Darwin Hospital.
STRATEGI MEDICATION SAFETY DI OK
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
Consensus Recommendations for Improving
Medication Safety in the Operating Room
MEDICATION SAFETY DI ICU
Latar belakang
TERAPI STRESSFUL
OBAT
DI ICU 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 Amlodipin Furosemide
• HTN • Ankle Edema • Nausea
Metoklopramid
Levodopa • Movement
disorder
Drip fentanyl IV tdk
distop: Ileus
memburuk
Tonic-clonic seizures
selama terapi imipenem
pseudomonal pneumonia
Contoh strategi untuk mencegah
medication 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
Contoh strategi untuk mencegah
medication errors
Menghilangkan faktor risiko situasional
3. Supervisi trainee
Contoh strategi untuk mencegah
medication errors
Mencegah kelalaian dan error
1. Intensivist participation in ICU care
2. Adequate staffing
Antimikroba Drug
Dose
dan marker interaction &
adjustment
infeksi incompatibility
Usul
pemeriksaan ………?
penunjang
Pharmacist Participation
in ICU Care
Take Home Messagges
OK dan ICU merupakan unit kerja dengan
situasi High Risk.
Ada beberapa Risk Factors yg dapat
menimbulkan MEDICATION INCIDENT di OK
dan ICU.
Banyak best practices yang terbukti dapat
meningkatkan MEDICATION SAFETY di OK
dan ICU, termasuk OTOMATISASI.
APOTEKER dapat memberi kontribusi
signifikan dalam mewujudkan MEDICATION
SAFETY di OK dan ICU.
TERIMA KASIH