Analysis of the Factor Causing the Medication Error in the Process of Medicine Administration of the Patients at the Adult In-Care Room of Sangatta Regional General Hospital

Author(s):  
Gunani ◽  
Syahrir A. Pasinringi ◽  
Noer Bahry Noor
2020 ◽  
pp. 211-218
Author(s):  
Pat Croskerry

In this case, a middle-aged male presents to the emergency department (ED) of a general hospital with dizziness and weakness and a history of falling the previous day associated with seizures. There is also a possibility of head injury. He is well known to the department and has been seen previously by the head of the department regarding inappropriate use of the ED. Some difficulty ensues in terms of whether he has been having seizures or not, which, combined with a medication error and a laboratory error, results in him being overdosed with a significantly toxic drug. The case is an example of groupthink as well as fundamental attribution error.


PHARMACON ◽  
2019 ◽  
Vol 8 (2) ◽  
pp. 360
Author(s):  
Dwi Baluntu ◽  
Weny I. Wiyono ◽  
Marina Mamarimbing

ABSTRACT This research to determine the knowledge and attitudes of health workers regarding reporting and reporting systems of medication errors has been carried out. Medication errors is any event that can cause or resulted  in improper health services or harm to patients that actually can be avoided. This research is a qualitative descriptive study using in-depth interviews with data analysis conducted using thematic analysis. The results showed that the health workers at Monompia General Hospital GMIBM Kotamobagu did not understand the reporting of medication errors, decision making to report medication errors was determined by the severity of the result of errors and lack of reporting due to fear of disciplinary action and fear of losing their jobs. Monompia General Hospital GMIBM Kotamobagu City continues to strive to improve the quality of health services, but the limitations of facilities and infrastructure as well as human resources were the obsracles. Keywords : Knowledge, Medication Errors, Reporting System ABSTRAK Telah dilakukan penelitian untuk mengetahui pengetahuan dan sikap tenaga kesehatan mengenai pelaporan dan sistem pelaporan medication error. Medication error merupakan setiap kejadian yang dapat menyebabkan atau berakibat pada  pelayanan kesehatan yang tidak tepat atau membahayakan pasien yang sebenarnya dapat dihindari. Penelitian ini merupakan penelitian yang bersifat deskriptif kualitatif menggunakan wawancara mendalam dengan analisis data yang dilakukan menggunakan tematik analisis. Hasil penelitian menunjukan bahwa tenaga kesehatan  di RSU Monompia GMIBM Kota Kotamobagu belum memahami mengenai pelaporan medication error, pengambilan keputusan untuk melaporkan kesalahan pengobatan ditentukan oleh tingkat keparahan hasil dari kesalahan dan minimnya tingkat pelaporan disebabkan karena tenaga kesehatan takut tindakan disiplin serta takut kehilangan pekerjaan. RSU Monompia GMIBM Kota Kotamobagu terus berupaya untuk meningkatkan mutu pelayanan kesehatan, tetapi keterbatasan sarana dan prasarana serta sumber daya manusia menjadi kendala tesendiri. Kata kunci : Pengetahuan, Medication error, sistem pelaporan


2017 ◽  
Vol 5 (2) ◽  
pp. 84
Author(s):  
Ni Luh Putu Nurhaeni ◽  
Ketut Suarjana ◽  
I Made Ady Wirawan

Background and purpose: Medication error is any preventable event that may lead to inappropriate medication use or patient harm. Prescription error, one component of medication error, at Sanglah General Hospital Denpasar is high. An electronic prescribing has been piloted at Angsoka Ward, Sanglah General Hospital Denpasar to reduce prescription errors. However, the evaluation of such implementation is never been conducted. This study aims to evaluate the effect of electronic prescribing on prescription errors at Sanglah General Hospital Denpasar.Methods: An evaluation study was conducted by adopting pre and post control design at Sanglah General Hospital Denpasar. Prescription errors at Angsoka Ward where the electronic prescribing is implemented, were compared to Kamboja Ward that uses manual prescribing. Heterogeneity of patients in these two wards was comparable. Prescription samples were selected using a simple random sampling. Prescription samples prior to implementation of electronic prescribing were taken from June and July 2016, while samples after implementation were taken from March and April 2017. Prescription samples from the control group were also taken from the same periods. A total of 96 prescriptions were taken from each arm – leading to 384 prescription samples in total. Prescription error was evaluated using three requirements namely: administrative (9 components), pharmacy (5 components) and clinical (3 components).Results: Our study found that there was a significant difference of prescription errors between pre and post implementation of electronic prescribing at Angsoka Ward (p<0.05). The median values [IQR] for prescription error based on administrative requirements between pre and post intervention were 2 [3] vs. 0 [0] (p<0.001); based on pharmacy requirements were 1 [2] vs. 0 [0] (p<0.001); based on clinical requirements were 1 [2] vs 0 [0] (p<0,001). In contrast, prescription error based on administrative and pharmacy requirements in Kamboja Ward was insignificantly reduced. The median values [IQR] for prescription error based on administrative requirements between pre and post intervention were 2 [2] vs. 2 [2] (p=0.505) and based on pharmacy requirements were 1 [2] vs. 1 [1] (p=0.295). There was a significant difference of prescription errors (p<0.05) based on clinical requirements with median values [IQR] of 1 [1] vs. 1 [1]. Implementation of electronic prescribing reduced the proportion of prescription errors by 67.8%. After implementation of electronic prescribing, some errors were still apparent related to drug administration and order duplication.Conclusions: Implementation of electronic prescribing reduces prescription errors. Scaling-up of electronic prescribing followed by training on standardised prescribing practices are warranted.


Author(s):  
Ronald S. Weinstein ◽  
N. Scott McNutt

The Type I simple cold block device was described by Bullivant and Ames in 1966 and represented the product of the first successful effort to simplify the equipment required to do sophisticated freeze-cleave techniques. Bullivant, Weinstein and Someda described the Type II device which is a modification of the Type I device and was developed as a collaborative effort at the Massachusetts General Hospital and the University of Auckland, New Zealand. The modifications reduced specimen contamination and provided controlled specimen warming for heat-etching of fracture faces. We have now tested the Mass. General Hospital version of the Type II device (called the “Type II-MGH device”) on a wide variety of biological specimens and have established temperature and pressure curves for routine heat-etching with the device.


2005 ◽  
Vol 173 (4S) ◽  
pp. 34-34
Author(s):  
Viraj A. Master ◽  
Jennifer Young ◽  
Jack W. McAninch

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