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4. Presentasi PC to prevent ME

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Pharmaceutical Care To
Prevent Medication Error
Yulia Trisna
Department of Pharmacy
Cipto Mangunkusumo Hospital
Indonesia
“NHS faces 'potentially serious
problems' from wrong
prescriptions on the NHS.”
Daily Telegraph 15/12/9
2
Medication misadventures
(preventable)
(unpreventable)
Medication
Errors
ADEs
B
C
ADRs
D
A
(injury)
(No injury)
Bates DW et al. J. Gen Intern Med. 1995; 10:199-205
E
Medication error
Any preventable event that may
cause or lead to inappropriate
medication use or patient harm while
the medicine is in the control of the
health care professional or patient.
National Coordinating Council for Medication Error Reporting and
Prevention http://www.nccmerp.org
medication errors
Outcome
Multidisciplinary
Multifactorial
Multidisciplinary :
 Physician
 Pharmacist/Pharmacist Assistant/Pharmacy
Technician
 Nurse
 Administrator
 Manufacturer
 Patient/Family
Multifactorial :
 lack of knowledge/skills
 substandard performance
 behaviour
 poor system
Prescribing/ordering
Transcribing
Preparation/Dispensing
Administration
PATIENT
Types of medication error
• Illegible prescription
• Wrong route
• Wrong patient
•Wrong labeling
• Wrong drug
•Wrong storage
• Wrong dose
• Omission
• Wrong dosage form
• Commission
• wrong preparation
• Expired drug
• Duplication
“Swiss Cheese” Model of System Error: Example
Nurse didn’t
check the dose
Outocome:
Therapeutic
failure
Pharmacist didn’t
review the
prescription
Patient needs
a drug
Dr prescribed a
wrong dose
Pharmacist
Assistant
dispensed the
wrong dose
Adapted from Loyola University Health System Presentation Safety Science: Human Error, Quality and Patient Safety Committee, 2007
Barriers
Physician
Pharmacist/Pharmacist Assistant
Nurse
Patient
ADE
“Near Miss”
Pharmaceutical Care
What?
How?
• Patient-centered practice
• Practitioner’s responsibilities
to optimize patient’s drug
therapy and improve QoL
•
•
•
•
Assessment
Identification of DRP’s
Care Plan
Follow up
Type of DRP :
Untreated indication
 Improper Drug selection
 Subtherapeutic dose
 Supratherapeutic dose
 Adverse Drug Reaction
 Drug Interaction
 Failure to receive drug
 Drug use without indication

(Hepler & Strand, 1990)
Aims of Pharmaceutical Care
Effective
Safe
Drug therapy
Improve
QoL
Economic
Relations in drug therapy
Symptoms
related to
disease or
therapy
Human or
systematic
error
Drug
therapy
Van den Bemt,
Drug Safety 2000;22:321-33.
Opportunity
For Error
Pharmaceutical Care
Medication History Taking
Ward Round
Medication Review/Reconciliation
Drug Information
Drug Therapy Monitoring
Counseling
Adapted by P.Thornton from J. Reason, 9/01
Opportunity
For Error
Pharmaceutical Care
Medication History Taking
Ward Round
Medication Review/Reconciliation
Drug Information
Drug Therapy Monitoring
Counseling
Adapted by P.Thornton from J. Reason, 9/01
Activities
•
•
•
•
•
•
Medication History Taking
Medication Review
Ward Round
Drug Information
Counseling
Drug Therapy Monitoring
Medication History Taking






Drugs used prior to admission
Drug allergy
Adverse Drug Reaction
Medication error
Non compliance
Drug Mismanagement
Ward Round
Medication Reconciliation



To ensure accurate
information on medications
currently use
To identify intentional and
unintentional discrepancies
To resolve discrepancies :
COMMUNICATION !
Why Medication Reconciliation?
Discrepancies :
 Admission 22 %
 Transfer 66 %
 Discharge 12 %
Santell J. Journal of Qual and Patient Saf. 2006;32:225-9
Data JCAHO

Medication Reconciliation
in Hospital
A/E
Ward
Clinic
ICU
Medication Safety  Patient Safety
Communication, Communication, Communication
Standard
Medication Management & Use (MMU)
Joint Commission International (JCI)
Standard 4:


ME 5: Patient records contain a list of current medications
taken prior to admission, and this information is made
available to the pharmacy and the patient’s health care
practitioners.
ME 6: Initial medication orders are compared to the list of
medications taken prior to admission, according to the
organization’s established process.
Standard 4.3:
 ME 3: Medication information is kept in the patient’s
record or inserted into his or her record at discharge or
transfer.
Medication Review
Drug Information
Drug Therapy Monitoring
• Identifies DRP
• Gives recommendation
Counseling
•To ensure patient’s
understanding
regarding his/her
medications, and
enhance his/her
compliance.
Discharge Medications
Medication Errors
March-August 2013
Cipto Mangunkusumo Hospital
wrong dose
Frequency
wrong instruction
duplication
illegible prescription
Near Misses: 99.5%
non adherence
wrong drug
wrong dosage form
wrong amount of drug
wrong patient
no indication
others
0
100 200 300 400 500 600 700
N= 1777
Collaborative approach
Physician
Pharmacist
Patient
Carer
Other health
professionals
Information and Communication
THANK YOU
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