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ISFI :
THE SEMINAR ON APPLICATION OF DRUG DEVELOPMENT AND CURRENT
ISSUE OF SAFETY
HOTEL MILLENIUM, JAKARTA JULY 22nd 2009
AGENDA
BASIC CONCEPT OF PATIENT SAFETY
MEDICATION ERROR
MEDICATION-RELATED RISK MANAGEMENT
HIPPOCRATESS TENET
(460-335 BC)
Organisational &
Corporate Culture
Contributary Factors
Influencing
Clinical Practice
Management
Decisions/
Organisational
Processes
Error
Producing
Conditions
Error
Violation
Producing
Conditions
Violation
Latent Failures
1.
PATIENT
2.
TASK AND
TECHNOLOGY
Policy-making,
3.
INDIVIDUAL
Communicating
4.
TEAM
5.
WORK
ENVIRONMENT
Planning,
Designing ,
Task
Active Failures
( sharp end )
Emergency
Diagnose
Pemeriksaan
Pengobatan
Perawatan
Defence
Barriers
-Procedure
-Professionalism
-Team
-Individual
-Environment
-Equipment
Adapted from Reason (revised)
Patient factors
- Condition (complexity and
seriousness)
- Language and communication
- Personality and sosial factors
Task factors
- Task design and clarity of process
- Availability and use of protocols
- Availability and use of test results
Team factors
- Verbal and written communication
- Supervision and seeking help
- Leadership
Work environment
- Staffing levels and skill mix
- Workload and shift pattern
- Design, availibility and
maintenance of equipment
Institutionsl context
- Economic and regulatory context
- Social attitude to risk
In a Hospital :
Because there are
hundreds of
medications, tests
and procedures,
and many patients
and clinical staff
members in a
hospital, it is quite
easy for a mistake
to be made. . . .
MEDICATION ERROR
Medication error
Drug therapy is becoming more complex.
The potential for adverse drug events and
medication errors is a reality.
They occur in all parts of the medication
use system.
1. Incorrect dose
2. Medication inappropriate for medical condition
3. Failure to monitor for drug side effects
4. Communication failure between physician and patient
5. Failure to monitor for drug levels
6. Lack of knowledge of medication
7. Most appropriate medication not used
8. Inappropriate length of treatment
9. Failure to monitor drug effects
10. Inadequate medication history
MEDICATION-RELATED
RISK MANAGEMENT
39%
Transcribing
12%
Dispensing
11%
Administering
38%
JAMA 1995 Jul 5,274(1):29-34
Arjaty/IMRK/2008
Poor handwriting
Coumadin or Kemadrin ?
Lotrison or Lotrimin ?
Doxorubicin or Daunorubicin ?
Pentobarbital or Phenobarbital ?
Arjaty/IMRK/2008
STANDARDIZED ABBREVIATIONS
Examples
Hospital Strategies
Hospitals and other health care organizations work to reduce medication
errors by using technology, improving processes, zeroing in on errors that
cause harm, and building a culture of safety.
Pharmacy intervention:
It was a challenge for health care providers to ensure that patients
continued taking their regularly prescribed medicines when they
entered the hospital,
"Surgeons are not typically the original prescribers,
CPOE is effective in
reducing medication errors.
It involves entering
medication orders directly
into a computer system
rather than on paper or
verbally.
2.
3.
4.
5.
6.
CONCLUSION
FINAL WORD