medication error adalah kejadian merugikan pasien akibat penanganan tenaga kesehatan yang sebetulnya dapat diegah. Biasanya menyebabkan terjadinya pemakaian obat secara tidak tepat.

misalnya kemungkinan terjadinya toksisitas karena penggunaan obat yang salah, atau terjadinya interaksi obat saat obat itu diminum secara bersama –sama, padahal sesungguhnya obat tersebut tidak boleh diminum secara bersamaan.

Agar tidak terjadi medication error ada tahapan –tahapan yang harus dilalui :

a. skrining resep (melalui 3 macam, skriining administratif, skrining farmasetik, skrining klinik)

b.  Mengambil keputusan. Bisa saja keputusannya adalah menyiapkan obat namun juga menunda pemberian obat untuk informasi lebih dari dokter. atau diberikan obatnya namun dengan wanti –wanti jika tidak ada perubahan dalam tempo waktu dekat, maka saya (farmasis) harus melakukan tindakan.

Adapun penyebab umum medication error antara lain :

a. Terjadinya kegagalan berkomunikasi (Handwriting, ada obat yang nama latinnya mirip, pembacaan angka nol dan koma yang mirip, singkatan, dan lainnya)

b. Kesalahan perhitungan dosis (pediatrik biasanya menerima 10 kali dosis normal (15 % pediatrik)

c. penggunaan obat yang salah rutenya (enteral feeding suplement malah digunakan intravena. Contoh lain, obat tetes mata malah digunakan ditelinga, dan obat tetes telinga malah digunakan dimata

d. ketidak tahuan pasien

pasien yang tahu fungsi tiap obat apa, bagiamana harus bekerja, dan bagaimana obat itu bekerja akan meminimalkan kemungkinan terjadinya medication error. jalan keluar ini adalah conseling.

e. Terkadang rutinitas membuat kita menganggap bahwa pekerjaan kita belul padahal ada hal –hal yang tidak tepat. hal ini terjadi karena kita sering sekali mengerjakan satu hal. Karena rutinitas  membuat yang kurang betul ini menjadi betul. Jika kita terkadang ada masalah dirumah dan terbawa di kerja, maka juga akibatnya sama. Untuk mengatasi ini perlu adanya pembagian job dimana semua pekerja pernah melakukan pekerjaan pekerja lainnya dan double chek.

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