scholarly journals GAMBARAN KEJADIAN MEDICATION ERROR DI INSTALASI GAWAT DARURAT RSU ELIM RANTEPAO

PHARMACON ◽  
2019 ◽  
Vol 8 (1) ◽  
pp. 152
Author(s):  
Priskha Widiastuti ◽  
Gayatri Citraningtyas ◽  
Jainer P Siampa
Keyword(s):  
Data Collection ◽  
Medication Error ◽  
Medication Errors ◽  
Health Personnel ◽  
Dosage Form ◽  
Emergency Services ◽  
Descriptive Analysis ◽  
Medical Record Number ◽  
Prospective Data ◽  
Prescription Date

ABSTRACT Medication Error is an event that is detrimental to the patient due to errors in the administration of drugs during the handling of health personnel, which can actually be prevented. Data on incidents of medication errors at Elim Hospital, Rantepao in 2017 were 85 cases (0.085% of the total 98,892 prescription sheets served). This study aims to determine the incidence and the percentage of medication errors during the prescribing and dispensing phase in the Emergency Installation of Elim Hospital ,Rantepao. This research is a descriptive analysis with prospective data collection. The results showed that medication errors which occurred at prescribing stage included no prescription doctor's name was 9.19%, no medical record number was 6.13%, no doctor's initial was 99.61%, patient's name was not clear was 0.57% , there was no patient age, was 6.89%, no concentration / dosage was 2.68%, no dosage form was 52.10%, and no prescription date was  1.72%. While medication errors at the dispensing stage include taking the drug was 0.38% and the lack of drug prepared was 0.19%. Based on the results of the study, it can be concluded that the biggest occurrence of medication errors in Emergency Services at Elim Hospital, Rantepao was occurred in the prescribing phase.Keywords: medication error, prescribing, dispensing, Emergency Installation ABSTRAKMedication Error adalah kejadian yang merugikan pasien akibat kesalahan dalam pemberian obat selama penanganan tenaga kesehatan, yang sebetulnya dapat dicegah.  Data insiden kejadian medication error RSU Elim Rantepao pada tahun 2017 yaitu sebanyak 85 kasus (0,085 % dari total 98.892 lembar resep yang dilayani). Penelitian ini bertujuan menentukan kejadian dan persentase medication error pada fase prescribing dan dispensing di Instalasi Gawat Darurat RSU Elim Rantepao. Penelitian ini merupakan penelitian yang bersifat analisis deskriptif dengan pengumpulan data secara prospektif. Hasil penelitian menunjukkan bahwa medication error yang terjadi pada tahap prescribing meliputi tidak ada nama dokter penulis resep 9,19%, tidak ada nomor rekam medik 6,13%, tidak ada paraf dokter 99,61%, nama pasien tidak jelas 0,57%, tidak ada usia pasien 6,89%, tidak ada konsentrasi/dosis sediaan 2,68%, tidak ada bentuk sediaan 52,10 %, dan tidak ada tanggal pembuatan resep 1,72%. Sedangkan medication error pada tahap dispensing meliputi salah pengambilan obat 0,38% dan obat ada yang kurang 0,19%. Berdasarkan hasil penelitian maka dapat disimpulkan bahwa kejadian medication error di Instalasi Gawat Darurat RSU Elim Rantepao terbesar yaitu terjadi pada fase prescribing.Kata-kata kunci : medication error , prescribing, dispensing, Instalasi Gawat Darurat

scholarly journals IDENTIFIKASI MEDICATION ERROR PADA RESEP PASIEN POLI INTERNA DI INSTALASI FARMASI RUMAH SAKIT BHAYANGKARA Tk. III MANADO

PHARMACON ◽  
2019 ◽  
Vol 8 (2) ◽  
pp. 434
Author(s):  
Tiansi Maalangen ◽  
Gayatri Citraningtyas ◽  
Weny I. Wiyono
Keyword(s):  
Drug Delivery ◽  
Medication Error ◽  
Outpatient Clinic ◽  
Health Personnel ◽  
Dosage Form ◽  
Descriptive Analysis ◽  
Birth Date ◽  
Hospital Level ◽  
Prospective Data ◽  
Hard Drugs

ABSTRACTMedication Error is every event that can be avoided which can cause or result in improper drug service or harm the patient while the drug is under the supervision of health personnel or patients. The aim of the study was to find out the prevalence of Medication Errors, which occur, in the precscribing phase and the dispensing phase of internal outpatient clinic. This research is a descriptive analysis research with prospective data collection. Study sample is 332 prescriptions of internal outpatient clinic who entered the pharmaceutical installation of Bhayangkara Hospital, Level III, in the period of January 2019. The results showed that there was a Medication Error in both phases. Medication Error that occurs in the prescribing phase includes; no birth date (age) 80.12%, no dosage form 38.85%, no consentration/dosage 27.71%, incomplete prescription of hard drugs 6.32%, can’t read prescribing letter 3.01%, incorrect/unclear patient name 1.20 %, there is no number of drugs 0.30% and there are no administration rules 0.30%. Medication Error that occurs in the dispensing phase includes; drug delivery outside the instructions is 8.13%, the drug delivered is less that 1.81%, and writing etiquette is wrong or incomplete 0.30%. Based on the data above, it can be concluded that there is a potensial of Medication Error in the prescribing and dispensing phase at Bhayangkara Hospital, Level III, Manado.  Keywords: Medication Error, Prescribing, Dispensing, Clinic Internally Bhayangkara Hospital Tk.III Manado.  ABSTRAKMedication Error adalah setiap kejadian yang dapat dihindari yang dapat menyebabkan atau berakibat pada pelayanan obat yang tidak tepat atau membahayakan pasien sementara obat berada dalam pengawasan tenaga kesehatan atau pasien. Tujuan penelitian yaitu mengetahui prevalensi Medication Error yang terjadi pada fase prescribing dan fase dispensing pasien rawat jalan poli interna. Penelitian ini merupakan penelitian analisis deskriptif dengan pengumpulan data secara prospektif. Terhadap 332 resep pasien rawat jalan Poli Interna yang masuk di instalasi farmasi Rumah Sakit Bhayangkara Tk.III Manado periode bulan Januari 2019. Hasil penelitian menunjukkan bahwa  terjadi Medication Error pada kedua fase tersebut. Medication Error yang terjadi pada Fase prescribing meliputi; tidak ada tanggal lahir (usia) 80.12 %, tidak ada bentuk sediaan 38.85 %, tidak ada konsentrasi/dosis sediaan  27.71 %, tidak lengkap penulisan resep obat keras 6.32 %, tulisan resep tidak terbaca 3.01 %, salah/tidak jelas nama pasien 1.20 %, tidak ada jumlah obat 0.30 % dan tidak ada aturan pakai 0.30 %. Medication Error yang terjadi pada Fase dispensing meliputi; pemberian obat diluar instruksi 8.13 %, obat yang diserahkan kurang 1.81 %, dan penulisan etiket yang salah atau tidak lengkap 0.30 %. Berdasarkan data diatas dapat disimpulkan bahwa masih terjadi Medication Error pada fase prescribing dan dispensing di Rumah Sakit Bhayangkara Tk.III Manado. Kata kunci : Medication Error, Prescribing, Dispensing, Poli Interna Rumah Sakit        Bhayangkara Tk.III Manado.

scholarly journals FAKTOR PENYEBAB MEDICATION ERROR DI INSTALASI GAWAT DARURAT (IGD) RUMAH SAKIT BHAYANGKARA TK.III MANADO

PHARMACON ◽  
2019 ◽  
Vol 8 (2) ◽  
pp. 426
Author(s):  
Leydia Angkow ◽  
Gayatri Citraningtyas ◽  
Weny I. Wiyono
Keyword(s):  
Data Collection ◽  
Human Resources ◽  
Medication Error ◽  
Environmental Conditions ◽  
Health Workers ◽  
Phase Error ◽  
Descriptive Study ◽  
Prospective Data ◽  
Work Area ◽  
Drug Names

ABSTRACTPatients who enter the ECU room need fast and appropriate help, but in reality there are reports of Medication Errors in the ECU. The purpose of this research is to find out the causes factors of Medication Error in the prescribing and dispensing phase. This research is a descriptive study with prospective data collection using questionnaires. The results showed that the factors causing Medication Error on prescribing phase error included the workloads that were unbalanced of workloads and human resources (HR), interruptions which were interrupted by ringing the telephone, communication such as the incomplete writing of drug names, environmental conditions such as the temperature working area was less supportive while working, and education, namely prescription writing that does not meet the prescription completeness requirements. Factors that causes Medication Error on dispensing phase include workloads of health workers are not able to solve on the every of their own job, interruptions that interrupting working by telephone ringing, environmental conditions on the work area temperature is less supportive when working, education such as preparation of drugs that are not in recipe request, and communication, namely the communication system regarding the stock of pharmaceutical supplies in the Pharmacy Installation did not run smoothly.Keywords: Causes, Medication Error, Emergency Room, Bhayangkara Hospital.ABSTRAKPasien yang masuk IGD perlu pertolongan yang cepat dan tepat, namun kenyataannya terdapat pelaporan kejadian Medication Error di IGD. Tujuan penelitian yaitu mengetahui faktor penyebab Medication Error pada fase prescribing dan dispensing. Penelitian ini merupakan penelitian deskriptif dengan pengambilan data secara prospektif menggunakan kuisioner. Hasil penelitian menunjukkan bahwa faktor penyebab Medication Error fase prescribing meliputi beban kerja yaitu beban kerja dan SDM tidak seimbang, gangguan/interupsi bekerja yaitu terganggu dengan dering telepon, komunikasi yaitu penulisan nama obat tidak lengkap, kondisi lingkungan yaitu suhu area kerja kurang mendukung saat bekerja, dan edukasi yaitu penulisan resep yang tidak memenuhi syarat kelengkapan resep. Faktor penyebab Medication Error fase dispensing meliputi beban kerja yaitu tenaga kesehatan tidak mampu menyelesaikan sendiri setiap pekerjaan, gangguan/interupsi bekerja yaitu terganggu dengan dering telepon, kondisi lingkungan yaitu suhu area kerja kurang mendukung saat bekerja, edukasi yaitu penyiapan obat yang tidak sesuai permintaan resep dan komunikasi yaitu sistem komunikasi mengenai stok perbekalan farmasi di Instalasi Farmasi tidak berjalan lancar. Kata Kunci: Faktor penyebab, Medication Error, Instalasi Gawat Darurat, Rumah Sakit Bhayangkara

scholarly journals Are We Ready for Bioterrorism? Health Personnel were Affected by Contaminated Meat Cooked at a Daily Routine Hospital Kitchen

2019 ◽  
Vol 34 (s1) ◽  
pp. s102-s102
Author(s):  
Volkan Ülker ◽  
Özcan Erdoğan
Keyword(s):  
Health Personnel ◽  
Emergency Services ◽  
Patient Flow ◽  
Descriptive Analysis ◽  
Mass Casualty ◽  
Daily Routine ◽  
Susceptible Host ◽  
Intravenous Saline ◽  
Infection Control Committee ◽  
Foodborne Infection

Introduction:Salmonellae are gram-negative motile bacilli. The transmission of salmonellae to a susceptible host usually occurs from the consumption of contaminated foods. Most persons infected with Salmonella develop diarrhea, fever, and abdominal cramps 12 to 72 hours after infection. The illness usually lasts four to seven days, but can be severe enough to require hospitalization.Aim:Describe a hospital kitchen based mass foodborne infection.Methods:Descriptive analysis of the foodborne infection event.Results:310 health personnel were contaminated from lunch that was cooked at our hospital kitchen. On that day 70 patients came to the emergency department for complaints of vomiting, fever, and diarrhea. During the next two days, we canceled all planned surgical operations. At the second day, we followed 80 patients and third day 150 patients came to our emergency services. Our emergency services and ıntensive care units were blocked because of personnel illness. We examined all patients, got blood tests and stool stains and cultures. Because of this mass casualty contamination, our infection control committee gave formal information that suspicious of Salmonellosis. 13 of 310 infected health personnel were hospitalized. They got intravenous saline and electrolytes support like calcium and potassium. After two days we got Results of stool cultures, there was inoculation of Salmonella types. None of them died.Discussion:We realized that we are not ready for mass casualty incidents like this contamination. Because our patient flow was really blocked. We had to call in new doctors and nurses from different hospital staffs. The event was similar to bioterrorism conditions and we suddenly have to put in place hospital disaster plans at the beginning of decontamination. This situation made us to recognize bioterrorism agents like Salmonella types. We have to raise awareness of the community about chemical, biological, radiological and nuclear agents attacks.

scholarly journals P08 Ten-fold medication errors in a tertiary paediatric hospital

2020 ◽  
Vol 105 (9) ◽  
pp. e10.1-e10
Author(s):  
Caitlin Cubbin
Keyword(s):  
Critical Care ◽  
Data Collection ◽  
Medication Error ◽  
Medication Errors ◽  
Medication Administration ◽  
List Type ◽  
Contributing Factors ◽  
Paediatric Hospital ◽  
Medication Process ◽  
Data Collection Sheet

AimTo perform a retrospective analysis of tenfold medication errors between the 1st January 2017 and the 31st December 2018 and identify contributing factors.MethodInformation from all tenfold medication errors reported to the Ulysses system between 1st January 2017 and 31st December 2018 which met the criteria was inputted into a data collection sheet. Information gathered included the age of the patient, the time the error occurred, the location within the hospital, the point in the medication process the error occurred, the drug involved and the NCC-MERP category of harm assigned to the error. Reports were excluded if they were repeated entries or if they did not meet the criteria for a tenfold medication error. The total number of medication errors reported per month and the total number of admissions per month was also identified. Once data collection was complete, these errors were qualitatively analysed and compared with those of a previous audit using errors reported from 1st January 2013 to 31st December 2014.ResultsTenfold errors were most likely to be reported in the Critical Care areas (34.4% of tenfold errors being reported over the two-year period). Prescribing was the most common origin of error accounting for 54.3% of tenfold errors in 2017 and 51.7% in 2018. The most common category of harm assigned was category B (no harm – error did not reach patient) with a total of 40.6% of the errors reported. The age group with the highest number of errors reported was 29–364 days with 39.3% tenfold medication errors reported over the two-year period. Morphine was the most common drug involved accounting for 13.8% of errors reported.ConclusionThe findings from this report mirror the results from the previous audit performed in 2014 in respect to error origin and patient age. Tenfold prescribing errors have more chance of being intercepted before reaching the patient due to there being more steps in the process before administration, therefore it is less likely that errors that originate at prescribing will reach the patient. Tenfold administration errors were more likely to reach the patient and therefore to cause harm. Morphine was the most reported drug in both 2017/18 and the 2013/14 audit suggesting that more work needs to be done on the safe use of opioids. Critical Care was the location with the highest number of errors reported, patients in this area often require complex medication regimes increasing the likelihood of being involved in a medication error.1ReferenceBower R, Coad J, Manning J, et al. A qualitative, exploratory study of nurses’ decision-making when interrupted during medication administration within the paediatric intensive care unit. Intensive Crit Care Nurs 2018;44:11–17.

Percutaneous Tracheostomy: A Multidisciplinary Approach

2008 ◽  
Vol 18 (2) ◽  
pp. 87-98 ◽  
Author(s):  
Vinciya Pandian ◽  
Thai Tran Nguyen ◽  
Marek Mirski ◽  
Nasir Islam Bhatti
Keyword(s):  
Health Care ◽  
Quality Assurance ◽  
Data Collection ◽  
Health Care Professionals ◽  
Multidisciplinary Approach ◽  
Percutaneous Tracheostomy ◽  
Johns Hopkins Hospital ◽  
Prospective Data ◽  
Comprehensive Service ◽  
Over Time

Abstract The techniques of performing a tracheostomy has transformed over time. Percutaneous tracheostomy is gaining popularity over open tracheostomy given its advantages and as a result the number of bedside tracheostomies has increased necessitating the need for a Percutaneous Tracheostomy Program. The Percutaneous Tracheostomy Program at the Johns Hopkins Hospital is a comprehensive service that provides care to patients before, during, and after a tracheostomy with a multidisciplinary approach aimed at decreasing complications. Education is provided to patients, families, and health-care professionals who are involved in the management of a tracheostomy. Ongoing prospective data collection serves as a tool for Quality Assurance.

DEVELOPMENT OF A TEACHING BOOK BASED ON LOCAL WISDOM OF JEPARA DISTRICT FOR CLASS V ELEMENTARY SCHOOL STUDENTSDEVELOPMENT OF A TEACHING BOOK BASED ON LOCAL WISDOM OF JEPARA DISTRICT FOR CLASS V ELEMENTARY SCHOOL STUDENTS

2020 ◽  
Vol 4 (6) ◽  
Author(s):  
Zaenal Arifin
Keyword(s):  
Elementary School ◽  
Data Collection ◽  
Learning Outcomes ◽  
Elementary School Students ◽  
Descriptive Analysis ◽  
School Students ◽  
Initial Product ◽  
Class V ◽  
Validation Test ◽  
Analysis Technique

This study aims to: (1) develop thematic textbooks based on local wisdom of our best friend's environmental theme material for grade V elementary school students, (2) Know the validity, practicality and effectiveness of thematic textbooks based on local wisdom of our best friend's environmental theme material for grade students V elementary school. The development of thematic textbook learning media based on local wisdom uses the Research and Development (R & D) method. The development stages include: (1) Potentials and problems, (2) Data collection, (3) Product design, (4) Design validation, (5) Design revision, (6) Product testing, (7) Product revision (Sugiyono, 2016). The research was conducted with 33 students from class V SDN 2 Sendang Jepara Regency. Initial product development is a process of making media based on needs analysis. Expert testing or validation was carried out by 2 experts, namely media experts and material experts. The data collection method in this research is observation, interview, and questionnaire. The data analysis technique used descriptive analysis and comparison test of two independent groups, namely using the independent t-test. Based on the results of the trial, this thematic teaching material is very valid, very interesting, effective and can be applied in learning. This can be seen from the results of the validation test from three experts which show that the product is good. The results of the effectiveness test showed that the experimental class students had better learning outcomes than the control class. This means that textbooks based on local wisdom of Jepara Regency are developed effectively

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 How effective are electronic medication systems in reducing medication error rates and associated harm among hospital inpatients? A systematic review and meta-analysis

2020 ◽  
Author(s):  
Peter J Gates ◽  
Rae-Anne Hardie ◽  
Magdalena Z Raban ◽  
Ling Li ◽  
Johanna I Westbrook
Keyword(s):  
Systematic Review ◽  
Medication Error ◽  
Medication Errors ◽  
Meta Analysis ◽  
Error Rates ◽  
Prescribing Error ◽  
Before And After ◽  
Actual Harm ◽  
Computer Based ◽  
Wide Scale

Abstract Objective To conduct a systematic review and meta-analysis to assess: 1) changes in medication error rates and associated patient harm following electronic medication system (EMS) implementation; and 2) evidence of system-related medication errors facilitated by the use of an EMS. Materials and Methods We searched Medline, Scopus, Embase, and CINAHL for studies published between January 2005 and March 2019, comparing medication errors rates with or without assessments of related harm (actual or potential) before and after EMS implementation. EMS was defined as a computer-based system enabling the prescribing, supply, and/or administration of medicines. Study quality was assessed. Results There was substantial heterogeneity in outcomes of the 18 included studies. Only 2 were strong quality. Meta-analysis of 5 studies reporting change in actual harm post-EMS showed no reduced risk (RR: 1.22, 95% CI: 0.18–8.38, P = .8) and meta-analysis of 3 studies reporting change in administration errors found a significant reduction in error rates (RR: 0.77, 95% CI: 0.72–0.83, P = .004). Of 10 studies of prescribing error rates, 9 reported a reduction but variable denominators precluded meta-analysis. Twelve studies provided specific examples of system-related medication errors; 5 quantified their occurrence. Discussion and Conclusion Despite the wide-scale adoption of EMS in hospitals around the world, the quality of evidence about their effectiveness in medication error and associated harm reduction is variable. Some confidence can be placed in the ability of systems to reduce prescribing error rates. However, much is still unknown about mechanisms which may be most effective in improving medication safety and design features which facilitate new error risks.

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