MEDICATION SAFETY Kapt Nurul Amirah bt Daud (3015207) Jabatan Farmasi HATTM
MALAYSIAN PATIENT SAFETY GOALS Reference: Ministry of Health Malaysia. (2013). Malaysian Patient Safety Goals: Guidelines on Implementation & Surveillance. Official Portal University Malaya Medical Centre. Retrieved September 18, 2021, from https://www.ummc.edu.my/files/quality/DS1041_Malaysian%20Patient%20Safety%2 1. 2. 3. 4. 5. 6. 7.
SKOP Definisi & KPI Medication error & ADR Prescribing error: GPP Penerimaan: Semak, semak, semak Penyimpana n: LASA, HArM Administrasi Ubat: Dilution Protocol REPORTING
MEDICATION SAFETY Reference: 1. Ministry of Health Malaysia. (2013). Malaysian Patient Safety Goals: Guidelines on Implementation & Surveillance. Official Portal University Malaya Medical Centre. Retrieved September 18, 2021, from https://www.ummc.edu.my/files/quality/DS1041_Malaysian%20Patient%20Safety%2 2. Hospital Bahagia Ulu Kinta. (2018). POLISI AMALAN KESELAMATAN PENGUBATAN. Retrieved September 18, 2021, from https://file:///C:/Users/user/Downloads/HBUK%20POLISI%20AMALAN%20KESELAMATAN%20PENGUBATAN.pdf MEDICATION SAFETY KESELAMATAN PENGUBATAN References: 1. Ministry of Health Malaysia. (2013). Malaysian Patient Safety Goals: Guidelines on Implementation & Surveillance. Official Portal University Malaya Medical Centre. Retrieved September 18, 2021, from https://www.ummc.edu.my/files/quality/DS1041_Malaysian%20Patient%20Safety%2 2. Hospital Bahagia Ulu Kinta. (2018). POLISI AMALAN KESELAMATAN PENGUBATAN. Retrieved September 18, 2021, from https://file:///C:/Users/user/Downloads/HBUK%20POLISI%20AMALAN%20KESELAMATAN%20PENGUBATAN.pdf
SKOP Definisi & KPI Medication error & ADR Prescribing error: GPP Penerimaa n: Semak, semak, semak Penyimpan an: LASA, HArM Administrasi Ubat: Dilution Protocol REPORTING
ADVERSE DRUG REACTION Tindak balas yang berbahaya atau tidak disengajakan terhadap produk ubat yang diberikan mengikut dos standard dengan cara yang betul untuk tujuan pencegahan (profilaksis), diagnosis, atau rawatan. References: 1. National Pharmaceutical Regulatory Agency (NPRA), Ministry of Health Malaysia. (2021, August). Adverse Drug Reaction (ADR) / Adverse Event Following Immunisation (AEFI) Reporting: Manual for Healthcare Providers. National Pharmaceutical Regulatory Agency (NPRA). Retrieved September 23, 2021, from https://www.npra.gov.my/easyarticles/images/users/1047/Adverse-Drug-Reaction-ADR--Adverse-Event-Following-Immunisation-AEFI-Reporting-Manual-For-Healthcare-Providers.pdf Ubat-ubat farmaseutikal, OTC,supplemen, ubat tradisional Doktor, farmasis, doctor gigi, jururawat, PPP Digunakan untuk indikasi yg tidak disarankan Produk tidak berdaftar Side effect yang sudah diketahui umum LAPORAN
MEDICATION ERROR Kesilapan penggunaan ubat-ubatan adalah sebarang perkara yang mengakibatkan penggunaan ubat-ubatan yang tidak sesuai atau memberikan kesan buruk kepada pesakit; pada masa ubat-ubatan dalam kawalan anggota kesihatan, pesakit atau pengguna. Medication error Actual error Already reach patient Detected by patient Near miss Potentially cause harm but did not reach patient Corrected before reach patient References: 1. Hospital Bahagia Ulu Kinta. (2018). POLISI AMALAN KESELAMATAN PENGUBATAN. Retrieved September 18, 2021, from https://file:///C:/Users/user/Downloads/HBUK%20POLISI%20AMALAN%20KESELAMATAN%20PENGUBATAN.pdf 2. Pharmaceutical Services Programme, Ministry of Health Malaysia. (2019). GUIDELINE ON MEDICATION ERROR REPORTING SYSTEM. Portal Rasmi Kementerian Kesihatan Malaysia. Retrieved September 19, 2021, from https://www.moh.gov.my/moh/resources/penerbitan/Garis%20Panduan/Umum%20(KKM)/guideline-medication-error-reporting-system.pdf
PROSES PEMBEKALAN UBAT PEROLEHAN UBAT PENYIMPANAN UBAT PRESKRIB UBAT MEDICATION RECONCILIATION PENYARINGAN UBAT PENGISIAN UBAT PENDISPENSAN UBAT PENERIMAAN UBAT DARI FARMASI PEMBEKALAN UBAT KPD WAD/ KLINIK ADMINISTRASI UBAT
TYPES OF MEDICATION ERROR Prescribing error Omission error Wrong time error Unauthorized drug error Dose error Dosage-form error Drugpreparation error Route of administration error Administration -technique error Deteriorated drug error Monitoring error Compliance error Other medication error 9/13
BAGAIMANA CARA UNTUK MENGELAKKAN/MENGURANGKAN MEDICATION ERROR?
SKOP Definisi & KPI Medication error & ADR Prescribing error: GPP Penerimaa n: Semak, semak, semak Penyimpan an: LASA, HArM Administrasi Ubat: Dilution Protocol REPORTING
PRESCRIPTION ERROR 1. 2. 3. 4. 5. 6. 7. Prescription error is the most crucial part of medication error because it is the initial point that can lead to medication error. If not detected, prescription error may lead to sequence of error throughout the whole process and actual medication error. Hence, it is important to “make it right the first time” when prescribing. “ “ References: 1. Medical Development Division, Ministry of Health Malaysia. (2020). Quick Guide: Preventing Prescription Error. Retrieved September 24, 2021, from https://hmelaka.moh.gov.my/v2/images/borang/Preventing%20Prescription%20Error%20-%20KKM%20Guideline%202020.pdf
SKOP Definisi & KPI Medication error & ADR Prescribing error: GPP Penerimaan: Semak, semak, semak Penyimpan an: LASA, HArM Administrasi Ubat: Dilution Protocol REPORTING
PENERIMAAN UBAT 1. 2. 3. 4.
SKOP Definisi & KPI Medication error & ADR Prescribing error: GPP Penerimaa n: Semak, semak, semak Penyimpanan: LASA, HArM Administrasi Ubat: Dilution Protocol REPORTING
LOOKS ALIKE, SOUNDS ALIKE
Ubat-ubatan LASA melibatkan: Ubat-ubat yang kelihatan seakan serupa dari segi rupa bentuk fizikal atau pembungkusan, mempunyai bunyi atau ejaan nama ubat yang seakan sama Ubat-ubatan LASA boleh menyebabkan kesilapan pengubatan yang mana pesakit menerima ubat yang salah dan mengalami kesan advers yang serius.
LANGKAH - LANGKAH PENCEGAHAN KESILAPAN BERKAITAN UBAT- UBATAN LASA Baca label ubat dengan teliti
Penggunaan Tall Man lettering cefOTAXime cefTAZIDime Contoh: metFORMIN metoPROLOL
No. Drug Name with Tallman Letters Confused With 1 amLODIPine aMILoride 2 ALPRAZolam LORazepam - clonazePAM 3 BISOprolol METOprolol - ATENolol 4 chlorproMAZINE chlorproPAMIDE 5 carBIMAzole carBAMAzepine 6 dilTIAZem diazePAM 7 diphenhydrAMINE dimenhyDRINATE 8 ENALApril CAPTOpril - PERINdopril 9 fluvoxaMINE fluPHENAZine - fluoXETINE 10 gliBENclamide gliCLAzide 11 hydroCHLOROthiazide hydrOXYzine - hydrALAZINE 12 Losartan TELMIsartan - IRBEsartan 13 METOprolol metFORMIN 14 medroxyPROGESTERone metroNIDAZOLE 15 niFEDIpine FELOdipine 16 neuroBION* neuroNTIN* - neuLIN* 17 prednisoLONE predniSONE 18 raNITIdine riMANTAdine 19 risperiDONE rOPINIRole 20 SETRAline STELLazine 21 MAdopaR* METHYLdopa
PENGGUNAAN LABEL AMARAN
SIMPAN SECARA BERASINGAN
Penyebaran maklumat mengenai ubatubatan LASA kepada semua anggota
HIGH ALERT MEDICATIONS
HIGH ALERT MEDICATIONS (HARMS) The Institute for Safe Medication Practices, US defines High Alert Medications as medications that bear a heightened risk of causing significant patient harm when these medications are used in error. Therefore, special precautions must be employed with their overall management .
LANGKAH -LANGKAH PENCEGAHAN KESILAPAN UBAT BERKAITAN HAMS Penggunaan pelekat
SILA RUJUK ‘GUIDELINE ON SAFE USE OF HIGH ALERT MEDICATIONS ‘ UNTUK MAKLUMAT LANJUT.
SKOP Definisi & KPI Medication error & ADR Prescribing error: GPP Penerimaa n: Semak, semak, semak Penyimpan an: LASA, HArM Administrasi Ubat: Dilution Protocol REPORTING
ADMINISTRASI UBAT 1. Baca label ubat dengan teliti dan berhati-hati, buat semakan secara ‘triangle check’ pada ubat, label ubat dan preskripsi atau carta pengubatan asal pesakit. 2. Ubat yang diambil untuk administrasi kepada pesakit hendaklah berdasarkan pembacaan pada label ubat dan bekas ubat, bukan dengan mengingati pada lokasi simpanan mahupun keadaan fizikal ubat dan bekas ubat. 3. Menggunakan 2 ‘identifier’ sebelum administrasi ubat kepada pesakit. 4. Berkomunikasi secara dua hala ketika proses administrasi ubat dengan mengalakkan pesakit terlibat secara aktif dan efektif. 5. Mengamalkan konsep 7R ketika proses administrasi ubat kepada Ubat Label Preskripsi Pesakit yang betul Ubat yang betul Dos yang betul Cara pengambilan yang betul Masa yang betul Dokumentasi yang betul Hak pesakit
6. 7. 8.
9. 10. 11. 12.
SKOP Definisi & KPI Medication error & ADR Prescribing error: GPP Penerimaa n: Semak, semak, semak Penyimpan an: LASA, HArM Administrasi Ubat: Dilution Protocol REPORTING
REPORT TO LEARN & GROW OUT OF MISTAKES
REFERENCES 1. Hospital Bahagia Ulu Kinta. (2018). POLISI AMALAN KESELAMATAN PENGUBATAN. Retrieved September 18, 2021, from https://file:///C:/Users/user/Downloads/HBUK%20POLISI%20AMALAN%20KESELAMATAN%20PENGUBATAN.pdf 2. Medical Development Division, Ministry of Health Malaysia. (2020). Quick Guide: Preventing Prescription Error. Retrieved September 24, 2021, from https://hmelaka.moh.gov.my/v2/images/borang/Preventing%20Prescription%20Error%20- %20KKM%20Guideline%202020.pdf 3. Ministry of Health. (2013). Malaysian Patient Safety Goals: Guidelines on Implementation & Surveillance. Official Portal University Malaya Medical Centre. Retrieved September 18, 2021, from https://www.ummc.edu.my/files/quality/DS1041_Malaysian%20Patient%20Safety%20Goals%20Guidelines%20on %20Implementation%20&%20Surveillance.pdf 4. National Pharmaceutical Regulatory Agency (NPRA), Ministry of Health Malaysia. (2021, August). Adverse Drug Reaction (ADR) / Adverse Event Following Immunisation (AEFI) Reporting: Manual for Healthcare Providers. National Pharmaceutical Regulatory Agency (NPRA). Retrieved September 23, 2021, from https://www.npra.gov.my/easyarticles/images/users/1047/Adverse-Drug-Reaction-ADR--Adverse-Event-FollowingImmunisation-AEFI-Reporting-Manual-For-Healthcare-Providers.pdf 5. Pharmaceutical Services Programme, Ministry of Health Malaysia. (2019). GUIDELINE ON MEDICATION ERROR REPORTING SYSTEM. Portal Rasmi Kementerian Kesihatan Malaysia. Retrieved September 19, 2021, from https://www.moh.gov.my/moh/resources/penerbitan/Garis%20Panduan/Umum%20(KKM)/guideline-medicationerror-reporting-system.pdf
TERIMA KASIH