Formulir Insiden Medication Error 5z3k1n

Kode Dokumen: SKP-14/016/2015

KOMITE MUTU DAN KESELAMATAN RUMAH SAKIT RSUD LASINRANG KABUPATEN PINRANG LAPORAN INSIDEN INTERNAL LAMPIRAN KHUSUS : “RINCIAN INSIDEN KESALAHAN PEMBERIAN OBAT” (Medication Error). 1. Tanggal : ………………………Waktu Insiden Jam : ....................................................................... 2. Insiden : ............................................................................................................................................ 3. Kronologis Insiden : (Diisi ringkasan insiden mulai saat sebelum kejadian sampai terjadinya insiden, Kronologis harus sesuai kejadian yang sebenarnya, bukan pendapat/asumsi pelapor: ........................................................................................................................................................... ........................................................................................................................................................... 4. Skrining resep : a. Pemeriksaan kelengkapan istrasi resep, yaitu : - Nama dokter : ....................................................................................................................... - Nomor Surat Izin Praktik (SIP): ............................................................................................ - Paraf / tanda tangan dokter: ................................................................................................. - Tanggal penulisan resep: ..................................................................................................... - Nama obat: ........................................................................................................................... - Jumlah obat: ......................................................................................................................... - Aturan pakai: ........................................................................................................................ - Nama: ................................................................................................................................... - Umur: .................................................................................................................................... - Berat badan: ......................................................................................................................... - Jenis kelamin: ....................................................................................................................... - Alamat / nomor telpon pasien: ............................................................................................. b. Pemeriksaan kesesuaian farmaseutik, yaitu: - Bentuk sediaan: .................................................................................................................... - Dosis: .................................................................................................................................... - Potensi: ................................................................................................................................. - Inkompatibilitas: .................................................................................................................... - Cara dan lama penggunaan obat: ....................................................................................... c. Pertimbangan klinik seperti: - Kesesuaian indikasi: ............................................................................................................. - Alergi: .................................................................................................................................... - Efek samping: ....................................................................................................................... - Interaksi: ............................................................................................................................... - Kesesuaian dosis: ................................................................................................................ d. Konsultasikan dengan dokter apabila ditemukan keraguan pada resep atau obatnya tidak tersedia: Ya / Tidak * 5. Faktor – faktor yang mempengaruhi kesalahan pemberian obat: a. Faktor insiden akibat obat: - Salah obat ............................................................................................................................. - Salah dosis ........................................................................................................................... - Salah label ............................................................................................................................ - Salah orang .......................................................................................................................... - Salah rute / cara pemberian ................................................................................................. - Pemberian obat yang sebenarnya kontraindikasi ................................................................ - Reaksi obat yang tidak diharapkan / Alergi ......................................................................... - Isilah informasi cara pemberian / nama obat yang diberikan .............................................. b. Faktor proses medikasi (Medication process): - Peresepan obat .................................................................................................................... - Persiapan / Peracikan obat .................................................................................................. - Pemberian obat .................................................................................................................... - Monitoring pemberian obat .................................................................................................. - Kualitas dan penyimpanan obat ........................................................................................... 6. Kemungkinan penyebab kesalahan pemberian obat: ..................................................................... * Coret yang tidak perlu

Investigator : …..................................................Tanda tangan : ......................................................