Kebijakan Sistem Penyimpanan Obat LASA, Alur Layanan, dan Formulir untuk Mencegah Dispensing Error
DOI:
https://doi.org/10.21776/ub.jkb.2016.029.03.1Abstract
Kejadian Nyaris Cedera (KNC) yang disebabkan oleh dispensing error pada instalasi farmasi RS di tempat studi terjadi pada dua bulan berturut-turut pada Januari dan Februari 2015. Tujuan penelitian ini adalah untuk mengidentifikasi akar masalah dispensing error tersebut sehingga terjadi KNC, identifikasi alternatif-alternatif solusi, pemilihan solusi dan implementasi solusi yang terpilih. Metode penelitian yang dilakukan adalah penelitian tindakan menggunakan bauran metode yang melewati tahapan-tahapan diagnosa, recconnaissance, rencana tindakan, tindakan, dan evaluasi. Diagnosa masalah adalah KNC yang disebabkan oleh dispensing error. Tahap recconnaissance dilakukan dengan mengumpulkan data melalui wawancara, diskusi kelompok terarah, pengamatan, dan telaah dokumen. Wawancara tidak terstruktur melibatkan 6 orang terdiri dari manajer, dokter, dan staf. Diskusi kelompok terarah melibatkan pimpinan rumah sakit, jajaran manajemen, dan kepala instalasi farmasi. Observasi dilakukan terhadap fasilitas fisik dan layanan resep. Hasil analisis data dituangkan dalam bentuk bagan tulang ikan. Faktor akar penyebab masalah terjadinya dispensing error adalah belum terformulasikannya kebijakan yang kemudian berdampak pada klaster masalah individu, tim, fasilitas, proses layanan, dan komunikasi. Jalan keluar utama dari berbagai penyebab akar permasalahan tersebut adalah formulasi kebijakan. Formulasi kebijakan menciptakan perbaikan pada prosedur layanan farmasi rawat jalan yang meliputi penerapan prinsip penyimpanan obat LASA, dan alur layanan farmasi rawat jalan yang berfokus pada pencegahan dispensing error meliputi perbaikan alur layanan mulai dari prosedur peresepan, penerimaan resep, penyiapan, etiketing, komunikasi informasi dan edukasi (KIE) obat sampai dengan prosedur penyerahan obat. Prosedur tersebut dapat diterima oleh instalasi farmasi sebagai prosedur pencegahan KNC.
Kata Kunci: Kejadian nyaris cedera, kesalahan penyiapan obat, penelitian tindakan
Downloads
References
Adrini TM, Harijanto T, and Woro E. Faktor-faktor yang Mempengaruhi Rendahnya Pelaporan Insiden di Instalasi Farmasi RSUD Ngudi Waluyo Wlingi. Jurnal Kedokteran Brawijaya. 2015; 28(2): 214-220.
Aldhwaihi K, Schifano F, Pezzolesi C, and Umaru N. Systematic Review of the Nature of Dispensing Errors in Hospital Pharmacies. Integrated Pharmacy Research and Practice. 2016; 5: 1-10.
Knudsen P, Herborg H, Mortensen AR, Knudsen M, and Hellebek A. Preventing Medication Errors in Community Pharmacy: Frequency and Seriousness of Medication Errors. Quality and Safety in Health Care. 2007; 16(4): 291–296.
Perwitasari DA, Abror J, and Wahyuningsih I. Medication Errors in Outpatients of a Government Hospital in Yogyakarta Indonesia. International Journal of Pharmaceutical Sciences Review and Research. 2010; 1(1): 8-10.
Szeinbach S, Vazquez ES, Parekh A, and Herderick M. Dispensing Errors in Community Pharmacy: Perceived Influence of Sociotechnical Factors. International Journal for Quality in Health Care. 2007; 19(4): 203-209.
Cheung KC, Bouvy ML, and Smet PAGMD. Medication Errors: The Importance of Safe Dispensing. British Journal of Clinical Pharmacology. 2009: 67(6): 676–680.
Keers RN, Williams SD, Cooke J, and Ashcroft DM. Causes of Medication Errors in Hospital: A Systemic Review of Quantitative and Qualitative Evidence. Drug Safety. 2013; 36(11): 1045–1067.
Anacleto TA, Perini E, Rosa MB, and César CC. Medication Errors and Drug-Dispensing Systems in a Hospital Pharmacy. Clinics. 2005; 60(4): 325-332.
Taylor JA, Loan LA, Kamara J, Blackburn S, and Whitney D. Medication Administration Variances Before and After Implementation of Computerized Physician Order Entry in a Neonatal Intensive Care Unit. Pediatrics. 2008; 121(1): 123–128.
Cina JL, Gandhi TK, Churchil W, et al. How Many Hospital Pharmacy Medication Errors Go Undetected? Joint Commission Journal on Quality and Patient Safety. 2006; 3(2):73-80.
Lingard L, Albert M, and Levinson W. Qualitative Research. Grounded Theory, Mixed Methods, and Action Research. The BMJ. 2008; 337: 459-461.
BaumF, MacDougall C, and Smith D. Participatory Action Research. Journal of Epidemiology & Community Health. 2006; 60(10): 854–857.
Ivankova NV. Mixed Methods Applications in Action Research. London: Sage Publication; 2014; p. 51.
Hampshire A, Blair M, Crown N, Avery A, and Williams I. Action Research: A Useful Method of Promoting Change in Primary Care? Family Practice. 1999; 16(3): 305-311.
Miles MB, Huberman AM, and Saldana J. Qualitative Data Analysis. A Methods Sourcebook. 3rd ed. Washington DC: Sage Publishing Company; 2014; p. 299.
Tomić B and Brkić VS. Effective Root Cause Analysis and Corrective Action Process. Journal of Engineering Management and Competitiveness. 2011; 1(1/2): 16-20.
Phillips J, and Simmonds L. Using Fishbone Analysis to Investigate Problems. Nursing Times. 2013; 109 (15): 18-20.
Allard J, Carthey J, Cope J, Pitt M, and Woodward S. Medication Errors: Causes, Prevention and Reduction. British Journal of Haematology. 2008; 116 (2): 255-265.
Schnoor J, Rogalski C, Frontini R, Engelmann N, and Heyde CE. Case Report of a Medication Error by Lookalike Packaging: A Classic Surrogate Marker of an Unsafe System. Patient Safety in Surgery. 2015; 9: 12.
James KL, Barlow D, Burfield R, Hiom S, Roberts D, and Whittlesea C. A Study of Unprevented Dispensing Incidents in Welsh NHS Hospitals. International Journal of Pharmacy Practice. 2007; 16(3): 175-188.
Al-Khani S, Moharram A, and Aljadhey H. Factors Contributing to the Identification and Prevention of Incorrect Drug Prescribing Errors in Outpatient Setting. Saudi Pharmaceutical Journal. 2014; 22(5): 429-432.
Aronson JK. Medication Errors: What They are, How They Happen, and How to Avoid Them. An International Journal of Medicine. 2009; 102(8): 513-521.
Barnsteiner J. Teaching the Culture of Safety. Online Journal of Issues in Nursing. 2011; 16(3): 1-13.
Donaldson MS. An Overview of to Err is Human: Re-emphasizing the Massage of Patient Safety. In: Hughes RG (Ed). Patient Safety and Quality: An Evidence Based Handbook for Nurses. Rockville; AHRQ Publication: 2008: pp. 1-9.
Soerensen AL, Lisby M, Nielsen LP, Poulsen BK, Mainz J. The Medication Process in A Psychiatric Hospital: Are Errors a Potential Threat To Patient Safety? Risk Management and Healthcare Policy. 2013; 6: 23-31.
Rahman Z and Parvin R. Medication Errors Associated with Look-alike/Sound-alike Drugs: A Brief Review. Journal of Enam Medical College. 2015; 5(2): 110-117.
Manasse HR, Eturnbull J, and Diamond LH. Patient Safety: Review of the Contemporary American Experience. Singapore Medical Journal. 2002; 43(5):254-262.
Solanki ND and Shah C. Root Cause Analysis of Medication Errors at a Multi-specialty Hospital in Western India. International Journal of Basic & Clinical Pharmacology. 2013; 2(6): 819-823.
Al Rahbi HAM, Al Sahbri RM, and Chitme HR. Intervention by Pharmacist in Out-patient Pharmaceutical Care. Saudi Pharmaceutical Journal. 2014; 22(2): 101-106
Downloads
Published
Issue
Section
License
Authors who publish with this journal agree to the following terms:- Authors retain copyright and grant the journal right of first publication with the work simultaneously licensed under a Creative Commons Attribution License that allows others to share the work with an acknowledgement of the work's authorship and initial publication in this journal.
- Authors are able to enter into separate, additional contractual arrangements for the non-exclusive distribution of the journal's published version of the work (e.g., post it to an institutional repository or publish it in a book), with an acknowledgement of its initial publication in this journal.
- Authors are permitted and encouraged to post their work online (e.g., in institutional repositories or on their website) prior to and during the submission process, as it can lead to productive exchanges, as well as earlier and greater citation of published work (See The Effect of Open Access).
