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Karakteristik ESO dan

upaya pengendalian
di masyarakat
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 Population and greatest risk of ADR

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Geriatric

 WHO defines elderly as individuals 60 years and older.

 16.6%, the average rate of ADR-related hospital

admissions is much greater in the older adult population
(Petrovic 2012).
 Studies from around the world have shown a direct
correlation between increasing age and the rate of ADRs
(Petrovic 2012; Kongkaew 2008)
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 The average patient older than 65 has two to

six prescription drugs and also takes one to
three OTC medications (Stewart 1994)

Detecting and preventing ADRs in the older

adult population remains a challenging, yet
important part of good clinical practice.
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Renal and hepatic impairment

 Most drugs are metabolized by the liver and

excreted by the kidneys. Impairment or failure
of either of these organs can affect drug
absorption, distribution, bioavailability, CYP
metabolism, and clearance
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 the presence of ascites in a patient with

cirrhosis can alter volume of distribution, af
ecting the bioavailability and elimination half-
life of some drugs and potentially leading to
an increased risk of ADRs (Lewis 2013).
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 Once considered non-preventable, some

ADRs may now be preventable because of
the emerging eld of pharmacogenomics
 Using pharmacogenomic testing to provide
personalized medicine can maximize
therapeutic benefit and avoid or reduce the
incidence of ADRs.
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Genetic variation

 An example is HLA- B*5701 screening for abacavir

hypersensitivity
 Patients who have this hypersensitivity reaction are
carriers of the HLA-B*5701 allele (Mallal 2008).
Although not all HLA-B*5701-positive patients will
have a hyper- sensitivity reaction to abacavir,
carriers of the allele are at higher risk of this
potentially life-threatening ADR.
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 the conversion of codeine to morphine

depends on CYP2D6 activity; CYP2D6
variants can be categorized as poor,
extensive, or ultrarapid metabolizers. Poor
metabolizers will be unable to convert
codeine to morphine efficiently and may not
experience adequate pain relief.
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 Obat-obat yang harus dimonitor pada pediatri :
z

1. Anti emetik
2. difenhidramin
4. laksatif
5. vitamin K
Clinical sign : oversedasi, lethargi, fall, hipotension
Laboratory finding :PTT > 100 sec, rising serum
creatinin, serum glukosa > 150 mg/dL
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ADVERSE DRUG EVENT TRIGGER
TOOL

 Diperlukan suatu database/ kumpulan data

berisi tanda-tanda Advers Drug Event yang
harus dikenali oleh petugas medis
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 ADR, dan ADE berperan dalam menciptakan

medication error
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ADR triger
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 Diphenhydramine (Benadryl) is frequently used for

allergic reactions to drugs but can also be ordered as a
sleep aid, a preoperative/pre- procedure medication, or
for seasonal allergies. If the drug has been
administered, review the chart to determine if it was
ordered for symptoms of an allergic reaction to a drug
administered either during the hospitalization or before
admission.
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Vitamin K

Determine whether vitamin K was used as a

response to a prolonged prothrombin time
(PTT) or INR. If either laboratory value is high,
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Flumazenil

This drug reverses benzodiazepine drugs.

Determine why the drug was used. If
hypotension or marked prolonged sedation
occurred following benzodiazepine
administration, an ADE has occurred.
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 Antiemetics
 Nausea and vomiting can be the result of drug
toxicity or overdose, particularly in patients with
impaired renal function. Drugs such as theophylline
preparations frequently cause nausea and vomiting
when levels are high. Antiemetics are also
commonly administered to patients postoperatively
or to those receiving chemotherapy. Professional
judgement must be used in these situations to
determine if an ADE has occurred.
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 Naloxone (Narcan)

 This is a powerful narcotic antagonist. If it has

been used, overdosage of narcotics is a
frequent finding. If it was used and the
patient’s condition did not change, doubt
excessive narcotic administration.
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 Antidiarrheals

 Look for antibiotic-caused Clostridium difficile

infections. If the C difficile was not ordered
and significant diarrhea occurred in a patient
receiving multiple antibiotics, it is likely that an
ADE occurred.
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 Glucose <50 mg/dl

 Not all patients will be symptomatic. Just because

serum glucose is low does not mean an ADE
occurred. Look for associated use of insulin, oral
hypoglycemic drugs, or evidence of symptoms and
administration of glucose (orally or intravenous). In
addition, look for signs or symptoms in the nursing
notes about lethargy, shakiness, etc
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 PTT >100 seconds

 This is a not infrequent occurrence when

patients are on heparin. As with vitamin K,
look for evidence of bleeding to determine if
an ADE has occurred. Use professional
judgement for patients with a high PTT
receiving heparin during a surgical procedure.
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 INR >6

 A not infrequent occurrence when patients

are on coumadin. Look for evidence of
bleeding to determine if an ADE has occurred.
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 WBC <3000 × 106/μl

 In some cases this will occur in response to drug

administration. Follow the WBC counts throughout
the admission and see what has happened. If
leukopenia is related to drugs such as
indomethacin, a fall in WBCs should be evident.
Don’t include patients currently receiving
chemotherapy.
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OPIOID

Change in mental status/delirium related

to opioid use
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RISK FACTOR
PRN or routine use of opioid medication
Opioid naiveté (someone who has not been taking opioids)
Opioids used in combination with sedatives or other opioids
History of opioid abuse
Opioid tolerance
Severe pain
Low fluid
intake/dehydration
Low body weight
History of head
injury, traumatic brain injury, or seizures
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 Falls COMMON SIGN
 Hallucinations

 Delusions

 Disorientation or

 confusion

 Light-headedness,

 dizziness, or vertigo
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 Lethargy or

 somnolence

 Agitation

 Anxiety

 Unresponsiveness

 Decreased BP, Pulse,Pulse oximetry ,Respirations

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CLINICAL INTERVENTION

 Administration of Narcan (NALOXON)

 Transfer to hospital

 Call to physician

 regarding new onset of relevant signs or symptoms

 Abrupt stop order for medication

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Hypoglycemia related to use of antidiabetic medication

 RISK FACTOR :

 Insulin use

 Sliding scale insulin use

 Oral hypoglycemic

 medication use

 Decrease in oral

 intake while taking antidiabetic medication

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COMMON SIGN
 Hypoglycemia (e.g., <50 mg/dl)

 Falls

 Headache

 nervousness, anxiety

 Sweating, chills

 Irritability, impatience

 Change in mental
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 Emotional changes

 (including new anger,

 sadness, stubbornness)

 Lightheadedness,

 dizziness

 Hunger

 Nausea

 Complaints of blurred or impaired vision

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CLINICAL INTERVENTION

 Stat administration of Glucagon or IV

 dextrose

 Administration of

 orange juice or other high sugar food or fluids in

response to blood sugar reading or symptoms
 Transfer to hospital
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Ketoacidosis related to insulin therapy

 RISK FACTOR :

 Diabetic residents with concurrent

 illnesses

 Infection

 Diabetic residents with consistently high blood glucose

levels
 Episodes of high
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 physical and/or emotional stress or trauma

 • A diabetic resident that frequently

 declines antidiabetic medications or

consumes foods not included in diet
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COMMON SIGN

 Lab results indicating:

 Profound
 dehydration
 Elevated blood
 glucose
 Ketones in urine

 Excessive thirst

 Frequent urination
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 Nausea/vomiting

 Abdominal pain

 Weakness/fatigue

 Shortness of breath

 Fruity-scented breath

 Confusion

 Rapid respirations

 Elevated temperature
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CLINICAL INTERVENTION

 Stat order for lab testing including to evaluate

blood sugar and fluid and electrolyte status
 Stat order for insulin

 New order for and administration of IV fluids

 Transfer to hospital