Professional Documents
Culture Documents
PROBLEM
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Classification
Need for additional therapy
Unnecessary drug therapy
Wrong drug
Dosage too low
Adverse drug reaction
Dosage too high
Non-compliance
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identification of DRP
Health Care
Records
Diagnosis
Allergies/cave
Prescription
Dispensed
Notes
Tests; lab, ADL
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Hospital Care, a supportive
process
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Hospital Care, a (non-)
supportive process
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Aim and objectives for
development of the LIMM
Develop and research a systematic model
for improved medication use during a
patient hospital stay.
Analyse problems and limitations in the
standard patient medication care process
Develop a structured team-based model
incl. Clinical pharmacy service
Study the process and outcomes (clinical,
humanistic, and economic)
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The LIMM-model
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Process for handling of DRP
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Ester 80 years old
Found on the floor in her apartment Friday
afternoon
At hospital admission
Slightly confused
High blood sugar
Low blood preassure
Medication interview by a pharmacist
Monday morning according to LIMM
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LIMM Medication Interview
Focus correct medication list
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LIMM Medication Interview Focus Knowledge abd
compliance
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MEDICATION ERROR
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DEFINISI
A medication error is defined as any preventable event that
may cause or lead to inappropriate medication use or
patient harm, while the medication is in the control of the
healthcare professional, patient, or consumer.
- NCC MERP
National coordinating council for Medication Error Reporting and
Prevention, 1996
Psychological classification of medication errors
Tipe error/ Contoh-contoh
Mistakes
Knowledge-based Memberikan penisilin tanpa menanyakan
errors riwayat alergi.
Rule-based errors Memberikan injeksi diklofenak di paha samping
bukannya di gluteus
Applying a bad rule Memberikan captopril dosis besar pada awal
gejala)
Slips (salah comot) and lapses (lupa) Bermaksud meresepkan
Slips of action chlorpromazine, tapi yang ditulis
(skill-based errors) chlorpropamide.
Lapses of memory Memberi beta blocker, tahu, tetapi, lupa bahwa
(skill-based errors) pasien penderita asma.
Medication error that leads to manslaughter THE LANCET Vol 355 March 18, 2000
Kejadian Medication Error
systems
o prescribing, o distribution,
o order communication, o administration,
o product labelling, o education,
o packaging and o monitoring,
o use.
o nomenclature;
o compounding dispensing,
Medication Error pada penderita yang dirawat di ICU
Di 2 RS Pendidikan Periode Januari-Desember 2002 (n=128)
ICU
1.7 errors/patient/day
Donchin, 1995
Medication Error pada pasien SC elektif
Di 2 RS Periode Januari-Desember 2002 (n=240)
Communicatio
n especially
System hand-offs
failures
Failure of
information,
planning
tests,
diagnoses
1. Kegagalan komunikasi
2. Praktek distribusi obat yang buruk
3. Dose miscalculations
4. Drug and drug device related problems
5. Pemberian obat yang keliru
6. Kurangnya informasi kepada pasien
Adverse Event
an injury caused by medical
management (rather than the
underlying disease) and that prolonged
the hospitalization, produced a
disability at the time of discharge, or
both.
19. Brennan, et al., 1991.
20. Leape, et al., 1991. See also; Brennan, et al., 1991.
Adverse drug events pada pasien rawat
inap (Classen et al., 1997).
Memperpanjang
Extra biaya Mortalitas
LOS
(Phillips, Christenfeld,
(Bates et al., 1997).
and McGlynn, 1998)
1. Informasi tentang adverse &
beneficial effect
Omission Commission
Severe
0s
Minor Moderate
00s
Pengadilan Santa Clara County Superior memutuskan kasus San Jose Medical Group,
Doctor Ilene Newman dan San Jose Mecical center. Brandon Nunez (3 tahun) hanya
dapat tinggal di rumah bersama orang tuanya, Carmelo and Sonia Nunez.
Sonia Nunez sedang in partu, 27 September 1999. Dokter terlambat saat akhirnya
memutuskan untuk operasi Caesar. Saat itu ketuban sudah pecah dan janin menjadi
hipoksia dan akhirnya menimbulkan kerusakan otat permanen pada Nunes.
Percent of Injuries due to Negligence
17 28
% %
AEs AEs
Proportion of Adverse Events Involving Negligence
Type of Event Proportion of Events
Due to Negligence
Operative
Wound infection 12.5
Technical complication 17.6
Late complication 13.6
Non-technical complication 20.1
Surgical failure 36.4
All 17.0
Non-operative
Drug-related 17.7
Diagnostic mishap 75.2
Therapeutic mishap 76.8
Procedure-related 15.1
System and other 35.9
All 37.2
Source Leape, 1991
Rates of Adverse Events and Negligence by
Specialty
Specialty Rate of Rate of
Adverse Negligence
Events (%) (%)
Orthopedics 4.1 22.4
Urology 4.9 19.4
Neurosurgery 9.9 35.6
Thoracic and cardiac surgery 10.8 23.0
Vascular surgery 16.1 18.0
Obstetrics 1.5 38.3
Neonatology 0.6 25.8
General surgery 7.0 28.0
General medicine 3.6 30.9
Other 3.0 19.7
P value <0.0001 0.64
Unauthorized
Pasien membeli antibiotika tanpa resep
Drug Error
Extra Dose
Dosis ganda
Error
Wrong Dose Dosis lebih besar atau lebih kecil dari yang
Error diresepkan dokter
Wrong Route
Cara pemberian keliru
Error
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Overview of off-label prescribing
Overall 21% of medication use is off-label
(Arch Intern Med. 2006; 166:1021-1026)
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Common off-label medications
Medication FDA indication Off-label use
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50
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STRATEGIES TO IMPROVE DRUG
USE
EDUCATIONAL REGULATORY
inform or persuade restrict decisions
MANAGERIAL
structure or guide decisions
EDUCATIONAL STRATEGIES
Data feedback
Analyze data:
are there deviations from guidelines
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