Formulir Insiden Medication Error

Kode Dokumen: SKP-14/016/2015

KOMITE MUTU DAN KESELAMATAN RUMAH SAKIT RSUD LASINRANG KABUPATEN PINRANG LAPORAN INSIDEN INTERNAL LAMPIRAN LAMPIRAN KHUSUS : “RINCIAN INSIDEN KESALAHAN (Medication Error ). ).

PEMBERIAN OBAT”

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 administrasi 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: Inkompatibilita s: .................................................... ........................................................ ........ - Cara dan lama penggunaan obat: ................................................... .................................... c. Pertimbangan Pertimbangan klinik seperti: - Kesesuaian indikasi: ....................................................... ...................................................... - Alergi: .................................................. ...................................................... ............................ - Efek samping: ....................................................... ........................................................ ........ - Interaksi: ....................................................... ...................................................... .................. - Kesesuaian dosis: .......................................................... ...................................................... d. Konsultasikan dengan dokter apabila ditemukan keraguan keraguan pada resep atau obatnya tidak tersedia: Ya / Tidak * 5. Faktor – faktor yang mempengaruhi kesalahan pemberian obat: a. Faktor insiden akibat insiden  akibat obat: - Salah obat ................................................... ........................................................ .................. - Salah dosis ................................................. ........................................................ .................. - Salah label .................................................. ........................................................ .................. - Salah orang ................................................ ........................................................ .................. - Salah rute / cara pemberian ............................................................................... .................. - Pemberian obat yang sebenarnya kontraindikasi kontraindikas i ........................................................ ........ - 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 : ......................................................