Medication Error Factors, Safety Guideline System, Flow of Drug Use, and Code of Conduct to Prevent Medication Error


Arvidareyna Panca
Nikma Fitriasari
Wiwik Supartiwi


Medication error is any preventable event that may lead inappropriate drug service or patient harm while the drug administration is in control of the healthcare professional or patient. This study aimed to analyze the factor that may lead the medication error and identify the medication error solution to pharmaceutical installation in research hospital, Indonesia. This study used an action research method. The research subject included doctor, pharmacist, pharmaceutical engineering personnel and nurses. Action research involves six process: diagnosis, reconnaissance, action plan, action, evaluation and monitoring the subject. Diagnosis were obtained from primary and secondary data. Primary data were obtained by interview, observation, and Focus Group Discussion (FGD). Secondary data were obtained from adverse event and near-miss events in medication error data in pharmacy installation. The results indicated that there were four major factor of medication error. First, prescribing error is an unclear written prescription, incomplete administration and unavailable prescription. Second, transcribe error is a misread of prescription drug that lead to mistreatment. Third, dispensing error is involved the misreading of prescription drug by pharmacist, wrong dose, wrong quantity of drugs, and incompetent pharmacist personnel. Fourth, administration error is an incorrect administration by hospital personnel. In conclusion, the establishment of safety guideline is important to medication error in pharmaceutical installation. The safety guidelines consist of the policy and standard operational procedure, flowchart of outpatient service, code of conduct of pharmacy safety and monitoring to ensure the quality of medical service.


How to Cite
Panca, A., Fitriasari, N. and Supartiwi, W. (2018) “Medication Error Factors, Safety Guideline System, Flow of Drug Use, and Code of Conduct to Prevent Medication Error”, Bioinformatics and Biomedical Research Journal, 1(2), pp. 28–32. doi: 10.11594/bbrj.01.02.01.


    Iskandar S (2016) pelayanan kesehatan dalam meningkat-kan kepuasan masyarakat di Rumah Sakit Panglima Sebaya Kabupaten Paser. eJournal Ilmu Pemerintahan 4 (2): 777-788.

    Anderson JG, Abrahamson K (2017) Your health care may kill you: medical errors. Study Health Technology Infor-mation 234:13-17.

    Adrini TM, Harijanto T, Woro UE (2015) Faktor-faktor yang Mempengaruhi Rendahnya Pelaporan Insiden di Instalasi Far-masi RSUD Ngudi Waluyo Wlingi. Jurnal Kedokteran Brawijaya. 28 (2): 214-220.

    Utarini A, Djasri H (2012) Keselamatan Pasien dan Mutu Pelayanan Kesehatan: Menuju Kemana?. Jurnal Mana-jemen Pelayanan Kesehatan 15 (4): 159-160.

    Duphily RJ (2014) Root Cause Investigation Best Practices Guide. Aerospace Report 2014. Accessed on January 7th, 2018.

    Greenwood DJ, Levin M (1998) Introduction to Action Research: Social Research for Social Change. London: Sage Publication.

    Tajuddin RS, Sudirman I, Maidin A (2012) Faktor Penyebab Medication Error di Instalasi Rawat Darurat. Jurnal Manajemen Pelayanan Kesehatan. 15 (4):182-187.

    Direktorat Bina Farmasi Komunitas dan Klinik Ditjen Bina Kefarmasian dan Alat Kesehatan (2008) Tanggung Jawab Apoteker Terhadap Keselamatan Pasien (Patient Safety). []. Accessed on December 23, 2017.

    Jas A (2009) Perihal Resep dan Dosis serta Latihan Menulis Resep. 2nd Edition. Medan: Sumatera Utara University Press.

    Budiono S, Sarwiyata TW, Alamsyah A (2014) Pelaksanaan program Manajemen Pasien dengan Risiko Jatuh di Rumah Sakit. Jurnal Kedokteran Brawijaya, 28 (1): 78-81.

    Morissan (2009) Teori Komunikasi Organisasi. Jakarta, Global Indonesia.

    Dani F (2012) Strategi Komunikasi Pembentukan Budaya Organisasi Baitul Arqam sebagai Sarana Pembentukan Bu-daya Organisasi Ala KH Ahmad Dahlan di Amal Usaha Muhammadiyah. Humanika Multidisciplinary Journal 14: 1-16.

    Purwanto H, Indiati I, Hidayat T (2015) Faktor Penyebab Waktu Tunggu Lama di Pelayanan Instalasi Farmasi Rawat Jalan RSUD Blambangan. Jurnal Kedokteran Brawijaya. 28 (2): 159-162.

    Colpaert K, Claus B, Somers A, Vanderwoude K. Robays A, Decruyenaere J (2006) Impact of Computerized Order Entry on Medication Prescription Error in The Intensive Care Unit: a Controlled Cross Sectional Trial. Critical Care 10 (1): 1-9.