Observational Study of Medication Error in Outpatient Pharmacy RSUP Dr. Hasan Sadikin Bandung
Medication error can occur at all stages, starting from prescribing, dispensing and administration of drugs. This study aims to assess the medication errors that occur in the pharmaceutical care process and analyze the cause of failure using the root cause analysis method, to improvement action and decrease the incidence of medication errors. The data were completeness prescription, frequency of dispensing error and completeness of drug information. The number of sample was 1100 prescriptions Prescribing errors were found the potential injury 15.69±11.51% and near missed error 0.5±0.55%. At dispensing stage, occur 427 incidences (9.71%), consist of two incidences (0.04%) for validation assessment regulations, 224 incidences (5.09%) of data entry, 113 incidences (2.57%) of retrieval of drugs, 19 incidences (0.43%) of fi ll in drugs, 69 incidences (1.57%) of fi nal check. At dispensing stage, near missed 330 incidences (7.51%) of near missed and 97 incidences (2.21%) of potential injury. Failure mode and effect analysis calculate of risk priority number, the drug retrieval (RPN 210) and data entry (RPN 126) were analyzed root cause of the analysis for man, material, method, facility and environment.
2. Departemen Kesehatan Republik Indonesia. Tanggung Jawab Apoteker Terhadap Keselamatan Pasien (Patient Safety), Jakarta.2008.
3. Dwiprahasto, I. Intervensi Pelatihan Untuk Meminimalkan Risiko Kesalahan pengobatan Dipusat Pelayanan Kesehatan Primer. Jurnal Berkala Ilmu Kedokteran. 2006; XXXVIII(1).
4. Purba, A.V., Soleha, M. dan Sari, I.D. Kesalahan dalam Pelayanan Obat (medication error) dan Usaha Pencegahannya, Buletin Penelitian Sistem Kesehatan, Volume I0. Januari 2007.
5. Peraturan Menteri Kesehatan RI Nomor 58 tahun 2014 tentang Standar Pelayanan Kefarmasian di Rumah Sakit.
6. Komite Keselamatan Pasien Rumah Sakit. Pedoman Pelaporan Insiden Keselamatan Pasien (IKP) (Patient Safety Incident Report). Perhimpunan Rumah Sakit Seluruh Indonesia. Jakara. 2007.
7. American Society of Hospital Pharmacists. ASHP Guidelines On Preventing Medication Error in Hospitals, Am J Hosp Pharm, 1993;50:305–14.
8. Greenall, J., Walsh, D. dan Wichman, K. Failure Mode and effect analysis: A tool for identifying risk in community pharmacies, ISMP Canda. 2007.
9. Kohn, L.T., Corrigan, J.M. dan Donaldson, M.S. (1999): To Err is Human building a safer health sistem, pada http://www/iom.edu/FIle.aspx?ID=4117 diakses 20 Desember 2014.
10. Milbank Memorial Fund. Proactive Hazard Analysis and Health Care Policy. Washington. 2007.
11. National Coordinating Council for Medication Error Reporting and Prevention. (2001): MERP Taxonomy of Kesalahan pengobatan, pada http://www.nccmerp. org/sites/default/files/taxonomy2001-07-31.pdf diakses tanggal 28 Desember 2014.
All articles in Jurnal Ilmu Kefarmasian Indonesia are an open-access article, distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License which permits unrestricted non-commercial used, distribution and reproduction in any medium.
This licence applies to Author(s) and Public Reader means that the users mays :
copy and redistribute the article in any medium or format
remix, transform, and build upon the article (eg.: to produce a new research work and, possibly, a new publication)
If you remix, transform, or build upon the article, you must distribute your contributions under the same license as the original.
- NO ADDITIONAL RESTRICTIONS:
You may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.
It does however mean that when you use it you must:
- ATTRIBUTION: You must give appropriate credit to both the Author(s) and the journal, provide a link to the license, and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests the licensor endorses you or your use.
You may not:
- NONCOMMERCIAL: You may not use the article for commercial purposes.
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.