Keselamatan Pasien dalam Proses

Dispensing Obat
17 Maret 2022 15:39

OUTLINE
• DISPENSING PROCESS
• DISPENSING ERROR
• AUTOMATED DISPENSING SYSTEM
• VIDEO

DISPENSING PROCESS (In Community and Hospital Pharmacies)

MEDICATION ERROR
- Any preventable event that may cause or lead to inappropriate medication use or patient harm while the
medication is in the control of the health care professional, patient or consumer
- Dapat terjadi pada 4 fase, yaitu kesalahan peresepan (prescribing error), kesalahan penerjemahan resep
(transcribing erorr), kesalahan menyiapkan dan meracik obat (dispensing erorr), dan kesalahan penyerahan
obat kepada pasien ( administration error) ) (Adrini TM, 2015)

DISPENSING ERROR
- Any unintended deviation from an interpretable written prescription or medication order. Both content and
labelling errors are included. Any unintentional deviation from professional or regulatory references or
guidelines affecting dispensing procedures.
- 1.5% of all the prescriptions in community setting have an error (95% CI 0.014 to 0.018).
- Jenis kasus dispensing error yang terjadi pada layanan farmasi adalah salah obat , salah kekuatan obat , dan
salah kuantitas

DISPENSING ERROR
A. INTERNAL ERROR (prevented error)
Detected within the pharmacy before issue of medications to the patients
B. EXTERNAL ERROR (unprevented error)
Detected after the medications had been issued and left the pharmacy

DISPENSING ERROR : CLASSIFICATION

1. Screening Error (Legal/ C linical)
2. Dispensing the wrong drug, strength, dosage form, quantity
3. Labelling drug with wrong directions
4. Completing drug administration

1. SCREENING ERROR (legal/clinical)

A community pharmacist failed to check the validity of a prescription and dispensed a medication on the basis
of an expired prescription

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 of an expired prescription
2. DISPENSING THE WRONG DRUG, STRENGTH, DOSAGE FORM, QUANTITY
- A community pharmacist failed to dispense the prescribed dosage form of a medication. For example, a
community pharmacist dispensed a modified release formulation when the conventional formulation was
prescribed
- A community pharmacist substituted an alternative formulation of a medication that contained sugar and
dispensed it to a diabetic patient instead of a sugar free formulation of the medication when the sugar free
formulation was available
3. LABELLING DRUG WITH WRONG DIRECTIONS
- A community pharmacist dispensed a medication that should be administered at specific times in relation to
meals but did not instruct the patient when to take it. For example, a community pharmacist did not instruct
the patient when to take the medication before or after the meal when meals affected drug absorption
- A community pharmacist dispensed warfarin for a patient without informing the patient that this drug might
increase the risk of bleeding
4. COMPLETING DRUG ADMINISTRATION
- A community pharmacist dispensed a controlled medication that should be entered in the controlled drug
registry (record) and failed to enter the dispensing information
- A community pharmacist dispensed a medication whose costs to be covered by a third party payer but filled the
wrong paying center in the dispensing form

Most common types of unprevented dispensing incidents at UK community pharmacies with manual dispensing
system
Most common types of unprevented dispensing incidents at UK hospital pharmacies with manual and automated
system
Most common types of prevented dispensing incidents at UK hospital pharmacies with manual and automated system
Most common types of unprevented dispensing incidents at US community pharmacies with manual and automated
dispensing system
Most common types of unprevented dispensing incidents at US hospital pharmacies with manual and automated
system

CAUSES OF DISPENSING ERROR

1. Workload, staffing levels, work interruptions
- Number of prescriptions dispensed per hour
- Pharmacist job dissatisfactions
- Pharmacy dispensary design
2. Similar drug names (incl. LASA)

3. Similar drug packaging (incl. Generic drugs)

4. Poor handwriting
- LASA

- Abbreviation
Uncommon, Unknown

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TYPES AND CAUSES OF DISPENSING ERROR

CAUSES OF DISPENSING ERROR

REDUCING THE RISKS OF DISPENSING ERRORS

- Ensure that each patient reviews the labels and contents of each container at the pharmacy (or at home before
using the medication if it has been collected by another person);
- The patient should always be asked their full name and date of birth when collecting prescribed drugs;
- The purpose of each medication should be discussed with the patient to help make sure it is being dispensed to
the intended patient

Errors reduced by automated medicines management system

“It may be that the errors avoided are those that pharmacists usually correct, but electronic prescribing ensures that

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“It may be that the errors avoided are those that pharmacists usually correct, but electronic prescribing ensures that
they are always correct before the first dose is due and has the potential to allow pharmacists to concentrate on
other aspects of the usage of medicines."

AUTOMATED DISPENSING SYSTEM

1. REPACKAGING SYSTEM
widely used in pharmacies in US, UK, Europe, Australia
2. WARD-BASED AUTOMATED DISPENSER
Widely used in US hospitals ; minus label generation , stock selection , medication assembly or product
labelling
3. PHARMACY BASED ORIGINAL PACK DISPENSER
4. widely used in US hospitals

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