scholarly journals PENGARUH PERAWAT TERHADAP KEJADIAN MEDICATION ERROR DI RUMAH SAKIT

2020 ◽  
Author(s):  
Januarizkah Napitu
Keyword(s):  
Patient Safety ◽  
Medication Error ◽  
Drug Administration ◽  
National Patient Safety Agency ◽  
National Patient ◽  
Administration Error

Saat ini medication error menjadi salah satu permasalahan kesehatan yang banyak menimbulkan berbagai dampak bagi pasien mulai dari resiko ringan bahkan resiko yang paling parah yaitu menyebabkan suatu kematian. Di Indonesia, prevalensi medication error berdasarkan data nasional kesalahan pemberian obat menduduki peringkat pertama sebesar 24,8% dari 10 besar insiden di rumah sakit yang pernah dilaporkan. Tahap dispensing adalah urutan pertama kesalahan dalam proses penggunaan obat. Pada penelitian di ruang perawatan pasien di RS Charitas Palembang (Simamora, 2011). Kejadian Tidak Diinginkan yang berhubungan dengan penggunaan obat sebanyak 76 kasus (26%) dan dari seluruh kejadian ini medication error yang paling sering terjadi adalah pada fase administration 81,32%, fase prescribing 15,88 % dan fase transcribing 2,8%.5 . Menurut National Patient Safety Agency (2004), medication error pada tahap administration error adalah jenis kesalahan yang paling sering terjadi dan menimbulkan dampak yang paling parah dibandingkan jenis kesalahan lainnya. Pihak yang paling bertanggung jawab dalam tahap drug administration adalah perawat, sebab perawat berkewajiban dalam tindakan pemberian obat.

Analisis Faktor Perawat Dalam Pelaksanakan Keselamatan Pasien Terhadap Kejadian Medication Administration Error di Rumah Sakit

2020 ◽  
Author(s):  
Bintang Marsondang Rambe
Keyword(s):  
Patient Safety ◽  
Literature Review ◽  
Medication Error ◽  
Medication Errors ◽  
Medication Administration ◽  
Prescribing Error ◽  
Medication Administration Error ◽  
Administration Error

Latar Belakang Keselamatan pasien (patient safety) rumah sakit adalah suatu sistem dimana rumah sakit membuat asuhan pasien lebih aman yang meliputi assessment risiko, identifikasi dan pengelolaan hal yang berhubungan dengan risiko pasien, pelaporan dan analisis insiden, kemampuan belajar dari insiden dan tindak lanjutnya serta implementasi solusi untuk meminimalkan timbulnya risiko dan mencegah terjadinya cedera yang disebabkan oleh kesalahan akibat melaksanakan suatu tindakan atau tidak mengambil tindakan yang seharusnya diambil yang dilakukan oleh perawat (Kemenkes, 2011).Salah satu kesalahan yang dapat merugikan pasien adalah medication error. Menurut WHO (2016) medication error adalah setiap kejadian yang dapat dicegah yang menyebabkan penggunaan obat yang tidak tepat yang menyebabkan bahaya kepasien, dimana obat berada dalam kendali profesional perawatan kesehatan. proses terjadi medication error dimulai dari tahap prescribing, transcribing, dispensing,dan administration. Kesalahan peresepan (prescribing error), kesalahan penerjemahan resep (transcribing erorr), kesalahan menyiapkan dan meracik obat (dispensing erorr), dan kesalahan penyerahan obat kepada pasien (administration error). Medication error yang paling sering terjadi adalah pada fase administration / pemberian obat yang dilakukan oleh perawat.Administration error terjadi ketika pemberian obat kepada pasien tidak sesuai dengan prinsip enam benar yaitu benar obat, benar pasien, benar dosis, benar rute pemberian, benar waktu pemberian dan benar pendokumentasian. Secara global, kesalahan pemberian obat (medication errors) sampai saat ini masih menjadi isu keselamatan pasien dan kualitas pelayanan di beberapa rumah sakit (Depkes RI, 2015; AHRQ, 2015). Perawat sebagai bagian terbesar dari tenaga kesehatan di rumah sakit, mempunyai peranan dalam kejadian medication error. Perawat berkontribusi karena perawat banyak berperan dalam proses pemberian obat. Pemberian obat/ Medication Administration adalah salah satu intervensi keperawatan yang paling banyak dilakukan, dengan sekitar 5- 20% waktu perawat dialokasikan untuk kegiatan ini (Härkänen et al.,, 2019). Pemberian obat juga mencakup tugas-tugas lain, seperti menyiapkan dan memeriksa obat obatan, memantau efek obat-obatan, mengedukasi pasien tentang pengobatan, dan memperdalam pengetahuan perawat tentang obat – obatan sendiri (DrachZahavy et al., 2014 dalam Yulianti et al., 2019)Berdasarkan isu tersebut, penulis tertarik untuk melakukan literature review terkait faktor perawat dalam pelaksanakan keselamatan pasien terhadap kejadian medication administration error di Rumah Sakit.

scholarly journals P044 Can an electronic prescribing system ensure clear anticoagulation discharge communication?

2019 ◽  
Vol 104 (7) ◽  
pp. e2.49-e2
Author(s):  
Susie Gage
Keyword(s):  
Patient Safety ◽  
Discharge Summary ◽  
Electronic Prescribing ◽  
List Type ◽  
Heparin Infusion ◽  
National Patient Safety Agency ◽  
High Dependency ◽  
National Patient ◽  
Discharge Summaries

AimThe National Patient Safety Agency (NPSA)1 identified heparin as a major cause of adverse events associated with adverse incidents, including some fatalities. By ensuring good communication, this should be associated with risk reduction.1 The aim of this study was to ensure there is clear anticoagulation communication on discharge, from the paediatric intensive care unit (PICU) electronic prescribing system (Philips), to the paediatric cardiac high dependency unit and paediatric cardiac ward. To investigate whether the heparin regimen complies with the hospital’s anticoagulant guidelines and if there is any deviation; that this is clearly documented. To find out if there is an indication documented for the heparin regimen chosen and if there is a clear long term plan documented for the patient, after heparin cessation.MethodsA report was generated for all patients who were prescribed a heparin infusion on PICU, between 1st January 2018 and 30th June 2018, from the Philips system. All discharge summaries from the PICU Philips system were reviewed. Only paediatric cardiac patients were included that had a heparin infusion prescribed on discharge, all other discharge summaries were excluded from the study. Each discharge summary was reviewed in the anticoagulant section; for the heparin regimen chosen, whether it complies with the hospital’s anticoagulant guidelines and if there was any deviation whether this was documented. The indication documented of which heparin regimen was chosen and whether a clear long term plan was documented after heparin cessation; for example if the patient is to be transferred onto aspirin, clopidogrel, warfarin or enoxaparin.Results82 discharge summaries were reviewed over the 6 month period between 1st January 2018 and 30th June 2018; 16 were excluded as were not paediatric cardiac, leaving 66 paediatric cardiac discharge summaries that were reviewed. 45 out of 66 (68%) complied with the hospital’s heparin anticoagulation guidelines. Of the 32% that deviated from the protocol; only 33% (7 out of 21) had a reason documented. Only 50% (33) of the summaries reviewed had an indication for anticoagulation noted on the discharge summary and 91% of discharge summaries had a long term anticoagulant plan documented.ConclusionThe electronic prescribing system can help to ensure a clear anticoagulation communication as shown by 91% of the anticoagulation long term plan being clearly documented; making it a more seamless patient transfer. On the Philips PICU electronic prescribing system there is an anticoagulant section on the discharge summary that has 3 boxes that need to be completed; heparin regimen, indication and anticoagulation long term plan. However, despite these boxes; deviations from the anticoagulant protocol were poorly documented as highlighted by only 33% having the reason highlighted in the discharge summary, only 50% of the indications were documented. Despite having prompts for this information on the discharge summary, the medical staffs needs to be aware to complete this information, in order to reduce potential medication errors and risk.ReferenceThe National Patient Safety Agency (NPSA). Actions that make anticoagulant therapy safer. NPSA; March 2007.

Recommendations from the British Committee for Standards in Haematology and National Patient Safety Agency

2007 ◽  
Vol 136 (1) ◽  
pp. 26-29 ◽  
Author(s):  
T. P. Baglin ◽  
D. Cousins ◽  
D. M. Keeling ◽  
D. J. Perry ◽  
H. G. Watson
Keyword(s):  
Patient Safety ◽  
National Patient Safety Agency ◽  
National Patient ◽  
British Committee

Checking for pregnancy before surgery: summary of a safety report from the National Patient Safety Agency

BMJ ◽  
2010 ◽  
Vol 341 (jul06 2) ◽  
pp. c3402-c3402 ◽  
Author(s):  
T. Lamont ◽  
T. Coates ◽  
D. Mathew ◽  
J. Scarpello ◽  
A. Slater
Keyword(s):  
Patient Safety ◽  
National Patient Safety Agency ◽  
Safety Report ◽  
National Patient

Patient Safety and Error Reduction

2013 ◽  
Author(s):  
Graham Brack ◽  
Penny Franklin ◽  
Jill Caldwell
Keyword(s):  
Patient Safety ◽  
Health Authority ◽  
Healthcare Professionals ◽  
Care Patient ◽  
Error Reduction ◽  
National Patient Safety Agency ◽  
Do No Harm ◽  
National Patient ◽  
Compensation Claims ◽  
Special Health

Most healthcare professionals take up their career because they want to make people better. It is rare—but not unknown—to find nurses deliberately harming patients. It is not always possible to cure a patient’s condition, and readers may be surprised to hear the view of Lord Justice Stuart-Smith that our ‘only duty as a matter of law is not to make the victim’s condition worse’ (Capital and Counties plc v Hampshire CC (1997) 2 All ER 865 at 883). Despite our best intentions, healthcare professionals do sometimes make the patient’s condition worse. There are too many instances of harm caused to patients. Not only does the patient suffer harm, staff will be upset (some may even give up their careers) and large compensation claims may be made which deplete NHS resources. According to the NHS Litigation Authority, in 2010–11 it received 8655 claims of clinical negligence and 4346 claims of non-clinical negligence against NHS bodies, and paid £863 million in connection with clinical negligence claims (NHSLA Annual Report and Accounts, 2011). To put that into perspective, NHS Warwickshire had a budget of £827m for that year, so this amount would fund a mediumsized PCT. For all these reasons, therefore, our first concern must be to do no harm to our patient. If we can improve their condition, so much the better, but at the very least we must leave them no worse off for having put themselves in our care. Patient safety must be everyone’s concern. It is monitored by the NHS Commissioning Board Special Health Authority. Until June 2012 there was a separate agency, the National Patient Safety Agency (NPSA), which produced a report in 2009 entitled Safety in doses: improving the use of medicines in the NHS . There were 811 746 reports to the NPSA in 2007, of which 86 085 were related to medication. The figures for July 2010– June 2011 show an increase to 1.27 million incidents, of which 133 727 were related to medication.

Open to scrutiny: incident reporting and transparency in the NHS

2010 ◽  
Vol 92 (3) ◽  
pp. 82-83
Author(s):  
Suzette Woodward
Keyword(s):  
Patient Safety ◽  
Management System ◽  
Improve Patient Safety ◽  
Incident Reporting ◽  
National Patient Safety Agency ◽  
National Patient ◽  
Reduce Risk ◽  
A Priority ◽  
Set Up ◽  
Improve Patient

The National Patient Safety Agency (NPSA) has been set up to improve patient safety for all NHS patients, wherever they are treated. An important part of the work of the NPSA is to learn from incidents that are reported nationally to provide sound, representative guidance and recommendations to reduce risk and harm in healthcare. Incident reporting should not be seen as a management system but as a culture in which patient safety is a priority.

The impact of the National Patient Safety Agency intravenous fluid alert on iatrogenic hyponatraemia in children

2010 ◽  
Vol 95 (Suppl 1) ◽  
pp. A46.1-A46
Author(s):  
S Drysdale ◽  
T Coulson ◽  
N Cronin ◽  
Z-R Manjaly ◽  
C Piyasena ◽  
...  
Keyword(s):  
Patient Safety ◽  
Intravenous Fluid ◽  
National Patient Safety Agency ◽  
National Patient ◽  
The Impact
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