MEDICATION

SAFETY
S KO P

Definisi &
REPORTING
KPI

Administrasi
Ubat: Medication
Dilution error & ADR
Protocol

Penyimpana
Prescribing
n: LASA,
HArM error: GPP

Penerimaan:
Semak,
semak,
semak
MM ED I C AT I O
E D I C AT I O N
N
S AS A
F FEETTYY
K E S E L A M ATA N
P E N G U B ATA N

Reference:
References:
1.
1. Ministry
Ministry ofofHealth
Health Malaysia.
Malaysia. (2013).
(2013). Malaysian
Malaysian Patient
Patient Safety Goals:Safety Goals:
Guidelines Guidelines on
on Implementation Implementation
& Surveillance. & Surveillance.
Official Portal Official
University Malaya Portal
Medical University
Centre. Malaya
Retrieved Medical
September Centre.
18, 2021, Retrieved September 18, 2021,
from https://www.ummc.edu.my/files/quality/DS1041_Malaysian%20Patient%20Safety%2
2. from https://www.ummc.edu.my/files/quality/DS1041_Malaysian%20Patient%20Safety%2
Hospital Bahagia Ulu Kinta. (2018). POLISI AMALAN KESELAMATAN PENGUBATAN. Retrieved September 18, 2021, from https://file:///C:/Users/user/Downloads/HBUK%20POLISI%20AMALAN%20KESELAMATAN%20PENGUBATAN.pdf
2. Hospital Bahagia Ulu Kinta. (2018). POLISI AMALAN KESELAMATAN PENGUBATAN. Retrieved September 18, 2021, from https://file:///C:/Users/user/Downloads/HBUK%20POLISI%20AMALAN%20KESELAMATAN%20PENGUBATAN.pdf
S KO P

Definisi &
REPORTING
KPI

Administrasi
Ubat: Medication
Dilution error & ADR
Protocol

Penyimpan
Prescribing
an: LASA,
error: GPP
HArM
Penerimaa
n:
Semak,
semak,
semak
 T Y P E S O F M E D I C AT I O N E R R O R

Prescribing Omission Wrong time Unauthorized

Dose error
error error error drug error

Drug- Route of Administration

Dosage-form Deteriorated
preparation administration -technique
error drug error
error error error

Other
Monitoring Compliance
medication
error error
error
 A DV E R S E D R U G
R E AC T I O N

• A response to a drug which is

noxious and unintended, and
which occurs at doses normally
used in man for the prophylaxis,
diagnosis, or therapy of
disease, or for the modification
of physiological function.
• To detect unknown and
unpredictable safety problems
that may surface only after a
drug is in the market and has
been used in the large
widespread population as
clinical trials involve smaller
numbers of selected people.
References:
1. National Pharmaceutical Regulatory Agency (NPRA), Ministry of Health Malaysia. (2021, August). Adverse Drug Reaction (ADR) / Adverse Event Following Immunisation (AEFI) Reporting: Manual for Healthcare Providers. National Pharmaceutical Regulatory Agency
(NPRA). Retrieved September 23, 2021, from https://www.npra.gov.my/easyarticles/images/users/1047/Adverse-Drug-Reaction-ADR--Adverse-Event-Following-Immunisation-AEFI-Reporting-Manual-For-Healthcare-Providers.pdf
 

 











S KO P

Definisi &
Reporting
KPI

Administrasi
Ubat: Medication
Dilution Error & ADR
Protocol

Penyimpanan Prescribing
(LASA, HArM) Error

Penerimaan
Semak, semak,
semak
PRESCRIPTION ERROR

1.
2.
3.
“ Prescription error is the most
crucial part of medication error
because it is the initial point
that can lead to medication
error.
4.
5. If not detected, prescription
error may lead to sequence of
6.
error throughout the whole
7. process and actual medication “
error. Hence, it is important to
“make it right the first time”
when prescribing.

References:
1. Medical Development Division, Ministry of Health Malaysia. (2020). Quick Guide: Preventing Prescription Error. Retrieved September 24, 2021,
from https://hmelaka.moh.gov.my/v2/images/borang/Preventing%20Prescription%20Error%20-%20KKM%20Guideline%202020.pdf
S KO P

Definisi &
REPORTING
KPI

Administrasi
Ubat: Medication
Dilution error & ADR
Protocol

Penyimpan
Prescribing
an: LASA,
error: GPP
HArM
Penerimaan:
Semak,
semak,
semak
 P E N E R I M A A N U B AT

1.

2.

3.

4.
S KO P

Definisi &
REPORTING
KPI

Administrasi
Ubat: Medication
Dilution error & ADR
Protocol

Penyimpanan:
LASA, Prescribing
HArM error: GPP
Penerimaa
n:
Semak,
semak,
semak
L O O K S AL I K E, SO U ND S AL I K E
 Ubat-ubatan LASA melibatkan:
Ubat-ubat yang kelihatan seakan serupa dari segi rupa
bentuk fizikal atau pembungkusan, mempunyai bunyi
atau ejaan nama ubat yang seakan sama

 Ubat-ubatan LASA boleh menyebabkan kesilapan

pengubatan yang mana pesakit menerima ubat yang
salah dan mengalami kesan advers yang serius.
L A N G K A H - L A N G K A H P E N C E G A H A N K E S I L A PA N
B E R K A I TA N U B AT - U B ATA N L A S A

Baca label
ubat dengan
teliti
Penggunaan Tall Man lettering

Contoh:

cefOTAXime
cefTAZIDime

metFORMIN
metoPROLOL
No. Drug Name with Tallman Letters Confused With
1 amLODIPine aMILoride
2 ALPRAZolam LORazepam - clonazePAM
3 BISOprolol METOprolol - ATENolol
4 chlorproMAZINE chlorproPAMIDE
5 carBIMAzole carBAMAzepine
6 dilTIAZem diazePAM
7 diphenhydrAMINE dimenhyDRINATE
8 ENALApril CAPTOpril - PERINdopril
9 fluvoxaMINE fluPHENAZine - fluoXETINE
10 gliBENclamide gliCLAzide
11 hydroCHLOROthiazide hydrOXYzine - hydrALAZINE
12 Losartan TELMIsartan - IRBEsartan
13 METOprolol metFORMIN
14 medroxyPROGESTERone metroNIDAZOLE
15 niFEDIpine FELOdipine
16 neuroBION* neuroNTIN* - neuLIN*
17 prednisoLONE predniSONE
18 raNITIdine riMANTAdine
19 risperiDONE rOPINIRole
20 SETRAline STELLazine
21 MAdopaR* METHYLdopa
PENGGUNAAN LABEL AMARAN
S I M PA N S E C A R A B E R A S I N G A N
Penyebaran maklumat mengenai ubat-
ubatan LASA kepada semua anggota
 HIGH ALERT
MEDICATIONS
 The Institute for Safe Medication Practices,
US defines High Alert Medications as
medications that bear a heightened risk
of causing significant patient harm when
these medications are used in error.
HIGH ALERT
M E D I C AT I O N S
(HARMS)
Therefore, special precautions must be
employed with their overall management.
LANGKAH-LANGKAH PENCEGAHAN
K E S I L A PA N U B AT B E R K A I TA N H A M S

Penggunaan pelekat
 SILA RUJUK
‘GUIDELINE ON SAFE
USE OF HIGH ALERT
M E D I C AT I O N S ‘
U N T U K M A K L U M AT
L A N J U T.
S KO P

Definisi &
REPORTING
KPI

Administrasi
Ubat: Medication
Dilution error & ADR
Protocol

Penyimpan
Prescribing
an: LASA,
error: GPP
HArM
Penerimaa
n:
Semak,
semak,
semak
 A D M I N I S T R A S I U B AT

1. Baca label ubat dengan teliti dan berhati-hati, buat Ubat

semakan secara ‘triangle check’ pada ubat, label ubat dan
preskripsi atau carta pengubatan asal pesakit.
2. Ubat yang diambil untuk administrasi kepada pesakit Label Preskripsi
hendaklah berdasarkan pembacaan pada label ubat dan
bekas ubat, bukan dengan mengingati pada lokasi
simpanan mahupun keadaan fizikal ubat dan bekas ubat.
Pesakit yang Ubat yang Dos yang
3. Menggunakan 2 ‘identifier’ sebelum administrasi ubat betul betul betul
kepada pesakit.
Cara
4. Berkomunikasi secara dua hala ketika proses administrasi pengambilan
Masa yang Dokumentasi
betul yang betul
ubat dengan mengalakkan pesakit terlibat secara aktif dan yang betul
efektif.
5. Mengamalkan konsep 7R ketika proses administrasi ubat Hak pesakit
kepada
6.

7.

8.
9.

10.

11.

12.
S KO P

Definisi &
REPORTING
KPI

Administrasi
Ubat: Medication
Dilution error & ADR
Protocol

Penyimpan
Prescribing
an: LASA,
error: GPP
HArM
Penerimaa
n:
Semak,
semak,
semak
Reporting Medication Error

https://mers.pharmacy.gov.my/
Reporting Adverse Drug Reaction

https://quest3plus.bpfk.gov.my/front-
end/adr_web_form_mid.php
REFERENCES
1. Hospital Bahagia Ulu Kinta. (2018). POLISI AMALAN KESELAMATAN PENGUBATAN. Retrieved September 18, 2021,
from https://file:///C:/Users/user/Downloads/HBUK%20POLISI%20AMALAN%20KESELAMATAN%20PENGUBATAN.pdf
2. Medical Development Division, Ministry of Health Malaysia. (2020). Quick Guide: Preventing Prescription Error.
Retrieved September 24, 2021,
from https://hmelaka.moh.gov.my/v2/images/borang/Preventing%20Prescription%20Error%20-
%20KKM%20Guideline%202020.pdf
3. Ministry of Health. (2013). Malaysian Patient Safety Goals: Guidelines on Implementation & Surveillance. Official Portal
University Malaya Medical Centre. Retrieved September 18, 2021,
from https://www.ummc.edu.my/files/quality/DS1041_Malaysian%20Patient%20Safety%20Goals%20Guidelines%20on
%20Implementation%20&%20Surveillance.pdf
4. National Pharmaceutical Regulatory Agency (NPRA), Ministry of Health Malaysia. (2021, August). Adverse Drug Reaction
(ADR) / Adverse Event Following Immunisation (AEFI) Reporting: Manual for Healthcare Providers. National
Pharmaceutical Regulatory Agency (NPRA). Retrieved September 23, 2021,
from https://www.npra.gov.my/easyarticles/images/users/1047/Adverse-Drug-Reaction-ADR--Adverse-Event-Following-
Immunisation-AEFI-Reporting-Manual-For-Healthcare-Providers.pdf
5. Pharmaceutical Services Programme, Ministry of Health Malaysia. (2019). GUIDELINE ON MEDICATION ERROR
REPORTING SYSTEM. Portal Rasmi Kementerian Kesihatan Malaysia. Retrieved September 19, 2021,
from https://www.moh.gov.my/moh/resources/penerbitan/Garis%20Panduan/Umum%20(KKM)/guideline-medication-
error-reporting-system.pdf