Gambaran Kejadian Medication Error pada Resep Anak di Apotek

Kelengkapan resep merupakan hal penting dalam peresepan karena bisa mengurangi adanya medication error. Medication error pada anak memiliki resiko lebih besar dibanding pasien dewasa karena anak membutuhkan perhitungan dosis berdasarkan usia, berat badan, luas daerah permukaan tubuh dan kondisi penyakitny Penelitian ini bertujuan untuk menganalisis pada aspek administratif resep anak usia 0-7 tahun di Apotek X Semarang dan Apotek Y di Ungaran bulan Januari-Mei 2021. Penelitian ini menggunakan rancangan penelitian deskriptif yang bersifat retrospektif, dengan melakukan analisis data terhadap kelengkapan resep diaspek administratif. Penetapan sampel pada penelitian ini menggnakan pengambilan sampel secara purposive sampling dengan mempertimbangkan kriteria yang telah ditentukan. Dari hasil penelitian yang dilakukan pada aspek kelengkapan resep bulan Januari-April 2021 didapatkan hasil sebagai berikut: Nama dokter 94,32 %, Nomor surat izin praktik (SIP)38,41 %, Alamat praktik dokter100%, Nomor telepon 97,73 %, Tanggal penulisan resep93,18 %, Paraf dokter51,85 %, Nama pasien100 %, Jenis kelamin pasien9,9 %, Umur pasien100 %, Berat badan pasien16,01 %. Kelengkapan administratif yang sudah memenuhi persyaratan adalah alamat praktek dokter, nama pasien, umur pasien. Kata kunci : Kelengkapan, Resep, Anak, Administratif

Analysis of medication errors during anaesthesia in the first 4000 incidents reported to webAIRS

Medication error is a well-recognised cause of harm to patients undergoing anaesthesia. From the first 4000 reports in the webAIRS anaesthetic incident reporting system, we identified 462 reports of medication errors. These reports were reviewed iteratively by several reviewers paying particular attention to their narratives. The commonest error category was incorrect dose (29.4%), followed by substitution (28.1%), incorrect route (7.6%), omission (6.5%), inappropriate choice (5.8%), repetition (5.4%), insertion (4.1%), wrong timing (3.5%), wrong patient (1.5%), wrong side (1.5%) and others (6.5%). Most (58.9%) of the errors resulted in at least some harm (20.8% mild, 31.0% moderate and 7.1% severe). Contributing factors to the medication errors included the presence of look-alike medications, storage of medications in the incorrect compartment, inadequate labelling of medications, pressure of time, anaesthetist fatigue, unfamiliarity with the medication, distraction, involvement of multiple people and poor communication. These data add to current evidence suggesting a persistent and concerning failure effectively to address medication safety in anaesthesia. The wide variation in the nature of the errors and contributing factors underline the need for increased systematic and multifaceted efforts underpinned by a strengthening of the current focus on safety culture to improve medication safety in anaesthesia. This will require the concerted and committed engagement of all concerned, from practitioners at the clinical workface, to those who fund and manage healthcare.

PENINGKATAN PERAN TENAGA KESEHATAN DAN MASYARAKAT DALAM MENCEGAH KESALAHAN PENGOBATAN

Providing safe services is important in the implementation of health services. Medication errors are a failure of the treatment process that has the potential to cause harm to patients. The incidence of treatment errors can be prevented through increased understanding of health workers and the community regarding the safety of treatment. The active role of patients and their families during treatment process can minimize harm that may happened. This program aims to increase the knowledge of health workers and community as an important element of health services in order to prevent the occurrence of medication error. Efforts to increase knowledge are carried out through the holding of webinars for the community related to 5 moments for medication safety and treatment safety training activities for health workers. Knowledge change was measured using a pre and posttest questionnaires. The target of activities amounted to 37 people and 15 health workers. The results of the analysis showed positive changes in average knowledge with an increase in community knowledge (97.3%) and health workers (100%). The results of this activity become the provision of the community or health workers to increase their role in the safety of treatment with knowledge that has been obtained during community service activities.Keywords: Medication safety, health workers, community, medication error AbstrakPenyediaan layanan yang aman penting dalam penyelenggaraan pelayanan kesehatan. Kesalahan pengobatan merupakan kegagalan proses pengobatan yang berpotensi menimbulkan bahaya bagi pasien. Insiden kesalahan pengobatan dapat dicegah melalui peningkatan pemahaman tenaga kesehatan dan masyarakat terkait keamanan pengobatan. Peran aktif pasien dan keluarganya dalam pelayanan kesehatan dapat meminimalisir bahaya yang mungkin timbul pada proses pengobatan. Tujuan pengabdian masyarakat ini adalah meningkatkan pengetahuan tenaga kesehatan dan masyarakat sebagai unsur penting pelayanan kesehatan agar dapat mencegah terjadinya kejadian medication error. Upaya peningkatan pengetahuan dilakukan melalui penyelenggaraan webinar bagi masyarakat umum terkait 5 moments for medication safety dan kegiatan pelatihan keamanan pengobatan bagi tenaga kesehatan. Perubahan pengetahuan diukur menggunakan kuesioner pre dan post test. Sasaran kegiatan berjumlah 37 masyarakat dan 15 tenaga kesehatan. Hasil analisis menunjukkan adanya perubahan positif rata-rata pengetahuan dengan peningkatan pengetahuan masyarakat (97,3%) dan tenaga kesehatan (100%). Hasil kegiatan ini menjadi bekal masyarakat ataupun tenaga kesehatan untuk meningkatkan perannya dalam keamanan pengobatan dengan pengetahuan yang telah diperoleh selama kegiatan pengabdian masyarakat dilakukan.Kata kunci: Keamanan pengobatan, tenaga kesehatan, masyarakat, kesalahan pengobatan

Perception on Occurrence of Medication Errors and Its Prevention among Nursing Officers

Aim of the study was to assess the perception on occurrence of medication error and to assess the perception on prevention of medication error among nursing officers in wards at a selected hospital, Raipur. Objectives To assess the perception on occurrence of medication error among nurses. To assess the perception on prevention of medication error among nurses. Review of literature was prepared relevant to the study. The conceptual framework of the study was based on” Imogene King’s Goal Attainment Theory”. Pilot study was done among nurses in selected wards at a selected hospital, Raipur. The main study was conducted in selected wards at a selected hospital, Raipur. A total of 60 nursing officers were included in the study and they were selected using non probability convenience sampling technique. The instrument used for data collection was standard 5-point Likert rating scale. Validity and reliability of the tool were done. Data were collected for the period of 4 weeks. Descriptive statistics was used to analyze the data. It was observed in the present study that majority (74%) of the total sample of nursing officers had adequate perception on occurrence of medication error and (82%) of the total sample of nurses had adequate perception on prevention of medication error. Key words: Medication errors, Perception, Occurrence, Prevention, Nursing officers.

Investigating the Role of Labelling and Packaging on Medication Error

<p>Medication administration error contributes to deaths and injury in hospitals, especially in the area of anaesthesia. Labelling and packaging contribute to medication error. The current study examined the role of labelling and packaging in medication error and compared medically trained and medically naive participants. Using eye-tracking equipment, Study 1A investigated the distribution of fixations across 32 pre-existing medication labels and packages. Both groups of participants fixated less on the dose and top of medications than on the name and ‘other’ features. Both medical experience and packaging type influenced on which label areas participants fixated. Medical participants fixated on dose more than control participants; there were no other differences between groups. In Study 1B participants viewed a target medication, they were then asked whether it was present in an array. The target was present in 50% of arrays. Distractors varied in similarity to the target. Signal detection theory analysis of discriminability through d’ revealed that medical participants were significantly better than control participants at discriminating whether or not the target was in the array. Bias analyses through C revealed that there was no difference between the biases of the two groups. Both groups of participants adopted a liberal criterion which increased the occurrence of false alarms. Across all trials, participants were most likely to select a distractor that differed only in the dose of the medication. Divided attention can increase medication error rates, therefore Study 1C utilised the same procedure as Study 1B and added a divided attention task. During the divided attention task participants saw a string of either five or seven letters and were later asked to recall one of the letters. Both groups of participants recalled fewer letters in the seven-letter compared to five-letter condition. There was no difference in the overall performance of the two groups on the divided attention task. Both groups showed a significant reduction in discriminability under the seven- compared to five-letter divided attention condition. Medical participants had significantly higher discriminability indices than control participants. Both groups of participants adopted a liberal criterion, however control participants were more biased than medical professionals. Control participants displayed an increase in bias in the seven-letter, compared to five-letter condition; the bias of medical participants was not influenced by the divided attention task. As in Study 1B, participants were most likely to select a distractor that differed only in the dose of the medication.</p>

Investigating the Role of Labelling and Packaging on Medication Error

<p>Medication administration error contributes to deaths and injury in hospitals, especially in the area of anaesthesia. Labelling and packaging contribute to medication error. The current study examined the role of labelling and packaging in medication error and compared medically trained and medically naive participants. Using eye-tracking equipment, Study 1A investigated the distribution of fixations across 32 pre-existing medication labels and packages. Both groups of participants fixated less on the dose and top of medications than on the name and ‘other’ features. Both medical experience and packaging type influenced on which label areas participants fixated. Medical participants fixated on dose more than control participants; there were no other differences between groups. In Study 1B participants viewed a target medication, they were then asked whether it was present in an array. The target was present in 50% of arrays. Distractors varied in similarity to the target. Signal detection theory analysis of discriminability through d’ revealed that medical participants were significantly better than control participants at discriminating whether or not the target was in the array. Bias analyses through C revealed that there was no difference between the biases of the two groups. Both groups of participants adopted a liberal criterion which increased the occurrence of false alarms. Across all trials, participants were most likely to select a distractor that differed only in the dose of the medication. Divided attention can increase medication error rates, therefore Study 1C utilised the same procedure as Study 1B and added a divided attention task. During the divided attention task participants saw a string of either five or seven letters and were later asked to recall one of the letters. Both groups of participants recalled fewer letters in the seven-letter compared to five-letter condition. There was no difference in the overall performance of the two groups on the divided attention task. Both groups showed a significant reduction in discriminability under the seven- compared to five-letter divided attention condition. Medical participants had significantly higher discriminability indices than control participants. Both groups of participants adopted a liberal criterion, however control participants were more biased than medical professionals. Control participants displayed an increase in bias in the seven-letter, compared to five-letter condition; the bias of medical participants was not influenced by the divided attention task. As in Study 1B, participants were most likely to select a distractor that differed only in the dose of the medication.</p>

Gambaran Medication Error Pada Resep Pasien Rawat Jalan di RSI Assyifa Sukabumi Periode Juni 2021

Medication error dapat didefinisikan sebagai kegagalan dalam proses pengobatan dan terjadinya kesalahan dalam pengobatan yang dapat memengaruhi keselamatan pasien. Medication error dapat terjadi pada 4 fase yaitu prescribing (penulisan resep), transcribing (penerjemahan resep), dispensing (proses penyiapan hingga penyerahan) dan administration (penggunaan). Tujuan penelitian ini adalah untuk mengetahui proporsi kejadian medication error pada fase prescribing, transcribing, dan dispensing di Instalasi Farmasi Rawat Jalan RSI Assyifa Sukabumi. Metode pengambilan data yang digunakan yaitu teknik cross sectional dengan mengamati dan mencatat temuan medication error pada lembar checklist pengamatan yang berisi 27 parameter untuk masing-masing resep. Sampel dalam penelitian ini sebanyak 371 lembar resep pasien yang dilayani di Instalasi Farmasi Rawat Jalan RSI Assyifa Sukabumi selama bulan Juni 2021. Hasil penelitian menunjukkan adanya kesalahan pada beberapa parameter yang berpotensi menyebabkan terjadinya medication error. Pada fase prescribing yaitu tidak adanya nomor rekam medis pasien sebanyak 100%, tidak ada tanggal lahir/usia pasien 91,64%, tidak ada jenis kelamin pasien 100%, tidak ada tanggal resep 49,87%, tidak ada paraf dokter 100%, dan tidak ada bentuk sediaan obat 96,77%. Pada fase transcribingyaitu tidakjelas/lengkap bentuk sediaan sebanyak 96,77%, tidak jelas/tidak lengkap aturan pakai 4,58%, tidak jelas/tidak lengkap usia pasien 91,64%, tidak jelas/tidak lengkap tanggal permintaan 49,87%, tidak jelas/tidak lengkap nama pasien 7,55%, tidak jelas/tidak lengkap nomor rekam medis pasien 100%, tidak jelas/tidak lengkap nama obat 0,27%, dan tidak jelas/tidak lengkap dosis pemberian obat 3,77%. Pada fase dispensing terjadi yaitu salah pengambilan obat sebanyak 1,89%, dan salah/tidak lengkap penulisan etiket 1,35%. Hasil penelitian menunjukkan nilai yang cukup tinggi pada beberapa parameter terutama pada fase prescribing.