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PHARMACY INTRAVENA ADMIXTURE

SERVICES (PIVAS)

 IV – Admixture
 Handling cytotoxic

Malang (Jatim), 12 Pebruai 2014


DRS. MASRIAL MAHYUDIN APT, MM
BACKGROUND
 Importance of Aseptic Technique
 Parenteral medications account for >40% of all
medications administered in institutional
practice
 Parenteral administration bypasses the skin
and gastrointestinal tract, the bodies natural
barriers to infection
 Giving a patient a contaminated product can
cause serious adverse effects including DEATH
Background (cont.)
Sources of product contamination
 People (most common)
 Touch contamination
 Generation of particulates from shedding cells or hair
 Supply air
 Heating Ventilation and Air Conditioning (HVAC)
 Infiltration
 Particles from adjacent spaces (e.g. anteroom)
 Internal generation
 Walls, floors, ceilings, packaging, equipment
Background (cont.)
Research
 Although medication errors can occur through any route of administration,
this online course will focus on the prevention of medication errors in the
dispensing and administration of intravenous (IV) medications.
 The administration of IV medications carries a relatively greater risk for
error than other routes of medication administration, in part because of
the complexity associated with their preparation and administration. For
example:
 1. IV medications are associated with 54% of potential ADEs.(15 ) :
a) Sixty percent of serious and life-threatening medication errors are
associated with IV medications. (16)
b) Infusion devices account for up to 35% of all medication errors that
result in significant harm. The most common error is incorrect manual
programming of infusion parameters (eg, rate, drug, dose) into
infusion devices. (Other errors include administering the wrong drug,
administering the right drug to the wrong patient, and tampering with
the recommended infusion parameters.)
2. Taxis,K.,Barber,W., reported that occured 249 mistakes by nurses from
430 times preparation intra vena drugs (dispencing and administration).
3. Lim.S., Princess Margareth Hospital, reported that cost saving for drugs
about $ 250.000/year and efficiency time of nurse is 330 hour/month
IV - ADMIXTURE
IV admixture merupakan proses pencampuran obat – obat
injeksi IV dari serbuk menjadi larutan ataupun pengenceran
larutan injeksi IV kedalam larutan IV steril untuk
menghasilkan sediaan steril yang siap diberikan secara IV
dengan teknik aseptis. (Termasuk pencampuran larutan pekat :
KCL, MgSO4, NaHCO3, NaCL 3% ke dalam larutan intravena steril)
Tujuan :
1. Untuk menjamin sediaan obat memiliki mutu sesuai
persyaratan (steril, kompatible, dan stabil)
2. Mencegah terjadinya kecelakaan kerja akibat
pencampuran yang tidak aseptik
3. Menurunkan angka kejadian infeksi nosokomial
4. Mendukung implementasi akreditasi Depkes versi baru
2012 yang tertera dalam Standar 5 Manajemen
Penggunaan Obat
DEFINITIONS (CONT.)
 Contamination – any effect or action that has a
negative impact on a product's integrity making
it unfit for use
 Chemical composition
 pH
 Sterility (e.g. microorganism contamination)
 Pyrogenicity
 Biological or therapeutic potency
 Physical appearance
 Particulate matter (e.g. dust, glass or precipitation)
DEFINITIONS
 Enteral
 Of or relating to the intestines
(e.g. by mouth, orally, per tube)
 Parenteral
 Introduced other than by way of the intestines
(e.g. intravenous, intramuscular, subcutaneous)

 Horizontal Flow (Laminar Flow Hood)


 Air blows towards worker
 Used for non-chemotherapy preparations
 Vertical Flow (Biological Safety Cabinet or Chemotherapy
Hood)
 Air blows from top down to maintain sterility and protect the
worker
 Used to make chemotherapy
Aseptic Technique
 Aseptic technique is the technique for manipulations
of compounded sterile products and parenteral
preparations that prevents contamination
 Aseptic technique requires specific manipulations for:
 Syringes
 Needles
 Vials
 Ampules
 Removal of packaging
 Assembling of sterile products
 Hand placement
Teknik Aseptic
Teknik aseptik bertujuan untuk meminimalkan terjadinya kontaminasi
mikroorganisme atau partikel kontaminan.
Faktor yang perlu diperhatikan meliputi:
1. Ruangan arus dibersihkan dan didesinfeksi
2. Dinding, lantai, dan langit-langit permukaannya harus halus tidak
ada celah dengan dilapisi epoksi
3. Dilengkapi dengan HEPA filter
Personel
4. Personel harus sehat jasmani dan terlatih atau mampu dalam
pelaksanaan aseptis (bergerak seperlunya).
5. Merupakan sumber kontaminan terbesar oleh karena itu sebelum
masuk ruang aseptik harus didesinfeksi dahulu di ruang transisi
Perlengkapan (baju, sarung kaki, tutup kepala, masker, sarung
tangan) harus disterilkan dahulu
Lanjutan

 Meja kerja, dinding samping dan belakang


merupakan daerah yang kemungkinan besar
terkontaminasi sehingga harus selalu
didekontaminasi seminggu sekali dan
didesinfeksi dengan aquadest dan alkohol
70% sebelum dan sesudah bekerja.
 Udara kembali disaring oleh HEPA filter
kabinet (±70%) kembali ke area kerja, sisanya
(± 30%) melalui HEPA filter ruangan.
EFFICIENCY OF PIVAS

No. BULAN PENDAPATAN PENGHEMATAN

1. Januari Rp. 2,247,038,484.00 Rp. 113,500,500.00

2. Februari Rp. 2,169,488,819.00 Rp. 90,800,400.00

3. Maret Rp. 3,024,856,762.00 Rp. 121,067,200.00

4. April Rp. 3,488,656,873.00 Rp. 116,022,733.33

5. Mei Rp. 3,205,318,364.00 Rp. 119,806,083.33

6. Juni Rp. 3,586,061,215.00 Rp. 123,589,433.33

7. Juli Rp. 2,584,730,465.00 Rp. 127,372,783.33

8. Agustus Rp. 2,657,100,514.00 Rp. 131,156,133.33

Total Rp. 22,923,251,496.00 Rp. 943,315,266.67


HOSPITAL PHARMACY SERVICES
& PROBLEM’s
DISTRIBUTION OF ADVERSE DRUG THE MOST COMMON
PRESCRIBING EVENTS ACCORDING TO THE STAGE
CATEGORIES OF ERRORS AND
OF THE ERROR IN THE MEDICATION
PROCESS
OMISSIONS

SCREENING

DISPENSING

ADMINISTRATION

MONITORING

FOLLOW UP
KCL CONCENTRATED
 CONCENTRATED POTASSIUM CHLORIDE HAS BEEN
IDENTIFIED AS A HIGHRISK MEDICATION BY
ORGANIZATIONS IN AUSTRALIA, CANADA, AND
THE UNITED KINGDOM OF GREAT BRITAIN AND
NORTHERN IRELAND (UK) (1).
 IN THE US, 10 PATIENT DEATHS FROM
MISADMINISTRATION OF KCL-CONCENTRATED
SOLUTION WERE REPORTED TO THE JOINT
COMMISSION IN JUST THE FIRST TWO YEARS OF
ITS SENTINEL EVENT REPORTING PROGRAMME:
1996–1997 (1).
 IN CANADA, 23 INCIDENTS INVOLVING KCL MIS-
ADMINISTRATION OCCURRED BETWEEN 1993 AND
1996 (2).
 THERE ARE ALSO REPORTS OF ACCIDENTAL DEATH
FROM THE INADVERTENT ADMINISTRATION OF
CONCENTRATED SALINE SOLUTION (3).
MICROBIOLOGY DATA IN ONCOLOGY WARD

Preparate Coloni amount


Ward third class 750 coloni
Ward first class 550 coloni
Ward VIP/VVIP class 225 coloni
Ward Isolate 40 coloni
Surgical Room 65 coloni
ICU Room 240 coloni
IV Preparation in third class room 50 coloni
IV Preparation in Second class room Sterile
IV Preparation in VIP class room Sterile
Kebijakan
Efisiensi

INPUT
• Resep dan PROSES
OUTPUT
Protokol
• SDM Model • Efektif
• Fasilitas yanfar •Efisien
• Aman
lama
Intervensi
Farmasis
COMPETENCY TO COMPREHENSIVE PHARMACEUTICAL CARE

A NA GEM. 15 %
M MACNY,
P H A R
IO
CT
SELE NING,
PL N EM ENT,
A
UR
PROC ORAGE,
S T ION
S T R IBU T
DI

PRODUCT.
PRARMACY
CLINICAL
PHARMACY : DRUG
HISTORY TAKING,
WARD ROUND, DRUG
REVIEW, DRUG
THERAPY
MONITORING,
10 % COUNSELING, DRUG
INFORMATION

75 %
PRINCIPLE OF INTRAVENA ADMIXTURE

1. For all intravena drug must sterile from


contamination (nosocomial infection)
2. Especially for cytotoxic/neoplastic drugs, we must
protect the operator from exposure the cytotoxic
drugs (carcinogenic, mutagenic, oncogenic etc)
3. Pharmacists responsible to realisize both of them.
Because they have knowledge and skill
Penanganan Obat Injeksi
(IV Admixture)
Risiko infeksi
Tingginya pasien Bahaya dari
tingkat bertambah  paparan obat
infeksi biaya kanker.
nosokomial pengobatan 

Standar Tanggungjawab Farmasis akan pelayanan


Pelayanan IV Admixture secara aseptis
Farmasi RS
Contoh :

Mutu :
Obat Injeksi P •Produk steril E
F
I
•Operator selamat
• Stabilitas ; suhu, E
Obat Kanker
V waktu
Efisien :
K
T
TPN A •Unit dose I

S
• Sisa obat utk F
pasien lain
SARANA DAN PRASARANA
1. FACILITY DESIGN
a. Clean room
b. Storage Area
c. Administrasi Area
d. Clean Area
e. Toilet Area
f. Ante Room
g. Pass Box
h. Laminar Air Flow (LAF)  
Lanjut Sarana & Prasarana (1)
CLEAN ROOM

1) 25 % - 30 % dari total area


2) Konstruksi khusus, dinding mudah dibersihkan
3) Partikel udara sangat dibatasi : kelas 100 partikel/lt udara
4) Aliran udara diketahui dan terkontrol
5) Tekanan ruangan diatur
6) Suhu dan kelembaban udara terkontrol Suhu : 18°-22° C
Kelembaban : 35 – 50 %
7) Dilengkapi HEPA filter
Lanjut 2
2. LAMINAR AIR FLOW (LAF)

1) Horizontal LAF
2) Dalam penggunaannya :
a. Aliran udara laminar : tidak turbulence
b. Meminimalkan kontaminasi
c. Peletakkan barang di dalam LAF harus diatur.
PELETAKAN BARANG DALAM LAF

 Barang yang dimasukkan harus terbatas


 Spasi dan layout :
- Objek besar : minimun berjarak antara
150 mm
- Objek kecil : minimum berjarak antara
50 mm
- Jarak antara objek dengan pinggir meja kerja
minimal 150 mm.
Lanjut 3

 Ruang antara : Ruang yang terletak antara ruang


cuci tangan dan clean room (barrier) pada
ruangan ini petugas menggunakan perlengkapan
steril
 Pass Box adalah jendela antara ruang
administrasi dan clean room (barrier) berfungsi
sebagai keluar masuk obat ke clean room
ALUR PELAYANAN IV- ADMIXTURE
CONTOH KASUS
KESIMPULAN
PERAN & KOMPETENSI APOTEKER PERLU DITINGKATKAN
UNTUK AKREDITASI : PATIENT SAFETY & UNIVERSAL COVERAGE

APOTEKER FRS HARUS MELAKSANAKAN FUNGSINYA SECARA


KOMPREHENSIF & SIMULTAN TERMASUK IV-ADMIXTURE
UNTUK MENJAMIN KEAMANAN DAN MUTU OBAT KEPADA
PASIEN DENGAN MEMPERTIMBANGKAN PROGRAM PATIENT
SAFETY.

UNTUK MELAKSANAKAN PERAN TERSEBUT DI ATAS


APOTEKER HARUS MEMILIKI KNOWLEDGE, SKILL & ATITUTE
AGAR PELAYANAN KEPADA PASIEN EFEKTIF DAN EFISIEN
TERUTAMA DALAM ERA JKN.
.
DALAM IMPLEMENTASI TUPOKSINYA HARUS DILAKUKAN
MONITORING DAN EVALUASI SERTA CONTINUEL
IMPROVEMENT, HAL INI DIPERLUKAN UNTUK EKSISTENSI
APOTEKER MENYONSONG UNIVERSAL COVERAGE

SEMOGA BERMANFAAT LAHR-BATIN

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