Prospective Identification of Prescribing Errors in the Outpatient Installation of Fatmawati General Hospital for the Period of November 2025
##plugins.themes.academic_pro.article.sidebar##
##plugins.themes.academic_pro.article.main##
Abstract
Prescribing errors often serve as an initial gateway to broader medication errors in hospital patient care. These errors must be minimized, particularly through digitalization efforts such as e-prescribing. This study aimed to identify prescribing errors in outpatient prescription services at Fatmawati Central General Hospital following the implementation of a hospital-wide e-prescribing system. A prospective direct observation method was applied to all prescriptions received at the Outpatient Pharmacy Depot, supported by clarification with the responsible pharmacists to ensure contextual accuracy and data validity. In November 2025, a total of 10,842 outpatient prescriptions were recorded. Several prescribing errors were still found during the observation period, including input errors such as mistyping and incorrect drug selection. High-risk drug interactions, especially among patients using warfarin, required closer monitoring. Patient education on the use of medications requiring special devices was also not consistently delivered. Meanwhile, prescriptions for narcotic and psychotropic medications complied with indication requirements and prescribing limits set by the National Formulary. These findings indicate that e-prescribing effectively reduces the frequency of errors compared with manual prescriptions. The results also underscore the need for enhanced prescription verification, improved patient counseling, and further optimization of the e-prescribing system.
##plugins.themes.academic_pro.article.details##
References
Agarwal SD, Landon BE, Ellenberg J. Patterns in outpatient benzodiazepine prescribing in the United States. JAMA Netw Open. 2019;2(1):e187399.
Agency for Healthcare Research and Quality (AHRQ). Electronic Prescribing. 2019.
Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. J Am Med Inform Assoc. 2008;15(5):585–600.
Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, on asthma inhaler technique. Patient Educ Couns. 2005;59(1):14–21.
Farhaty N, Sinuraya RK. Risiko peningkatan efek samping terhadap interaksi obat warfarin dan antibiotik. Farmaka. 2018;16(2).
Farrokh S, Nalleballe K, Onteddu S, Suarez JI, Bösel J, Shah VA. Bleeding risk with combining antiplatelets and anticoagulants for secondary stroke prevention: a propensity score–matched analysis. J Am Heart Assoc. 2025;14(16):e042767.
Feldstein AC, Smith DH, Perrin N, Yang X, Simon SR, Krall M, et al. Reducing warfarin medication interactions. Arch Intern Med. 2006;166(9):1009.
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. 2023.
Hitti E, Tamim H, Bakhti R, Zebian D, Mufarrij A. Impact of internally developed electronic prescription on prescribing errors at discharge from the emergency department. West J Emerg Med. 2017;18(5):943–50.
Holbrook A, et al. Evidence-based management of anticoagulant therapy. Chest. 2012;141(2 Suppl):e152S–84S.
Kaushal R, et al. Electronic prescribing improves medication safety in ambulatory care. J Gen Intern Med. 2010;25(6):530–6.
Kementerian Kesehatan Republik Indonesia. Permenkes No. 5 Tahun 2023 tentang Narkotika, Psikotropika, dan Prekursor Farmasi. 2023.
Kementerian Kesehatan Republik Indonesia. Permenkes No. 30 Tahun 2023 tentang Perubahan Penggolongan Narkotika. 2023.
Kim SY, Kang JY, Hartman JH, Park SH, Jones DR, Yun CH, et al. Metabolism of R- and S-warfarin by CYP2C19 into four hydroxywarfarins. Drug Metab Lett. 2012;6(3):157–64.
Kroll DS, et al. Prescribing practices of benzodiazepines in the United States. Psychiatr Serv. 2016;67(10):1095–101.
Lopes RD, Horowitz JD, Garcia DA, Crowther MA, Hylek EM. Warfarin and acetaminophen interaction: a summary of the evidence and biologic plausibility. Blood. 2011;118(24):6269–73.
Naseralallah L, Stewart D, Price M, Paudyal V. Prevalence, contributing factors, and interventions to reduce medication errors in outpatient and ambulatory settings: a systematic review. Int J Clin Pharm. 2023;45(6):1359–77.
National Coordinating Council for Medication Error Reporting and Prevention (NCC MERP). Medication Error Index. 2020.
Parra D, Beckey NP, Stevens GR. The effect of acetaminophen on the international normalized ratio in patients stabilized on warfarin therapy. Pharmacotherapy. 2007;27(5):675–83.
Roumeliotis N, Sniderman J, Adams-Webber T, Addo N, Anand V, Rochon P, et al. Effect of electronic prescribing strategies on medication error and harm in hospital: a systematic review and meta-analysis. J Gen Intern Med. 2019;34(10):2210–23.
Slight SP, et al. Errors and adverse events associated with computerized provider order entry: a systematic review. J Am Med Inform Assoc. 2018;25(5):693–702.
Wang M, Zeraatkar D, Obeda M, Lee M, Garcia C, Nguyen L, et al. Drug-drug interactions with warfarin: a systematic review and meta-analysis. Br J Clin Pharmacol. 2021;87(11):4051–100.
World Health Organization (WHO). Medication Errors: Technical Report. 2017.