Prospective Identification of Medication Error Incidents in the Inventory Stage of High-Alert Medications at the Central Pharmacy Warehouse of Fatmawati Central General Hospital for the November 2025 Period
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Abstract
The management of high-alert medications requires special attention due to their high risk of causing patient harm when errors occur. This study aims to identify deviations in the storage and distribution of high-alert medications at the Central Pharmacy Warehouse of Fatmawati Central General Hospital and to assess their compliance with the standards of the Ministry of Health (2019) and ISMP (2018). The method used was direct observation during November 2025. A total of 50 deviations were found, consisting of 26 cases related to labeling (76.5%) and 8 cases related to storage (23.5%). The most common deviations included the absence of “High Alert” labels, discrepancies in stock cards, and improper arrangement of medications according to risk categories. Based on the NCC MERP adaptation, all findings were classified as potential errors without immediate clinical impact but with the possibility of leading to medication errors. These results indicate that the labeling and monitoring system for high-alert medications at Fatmawati Central General Hospital has not been optimal, necessitating improvements through consistent labeling, separation of storage areas, and strengthened stock monitoring.
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References
2. Institute for Safe Medication Practices. ISMP list of high-alert medications in acute care settings. 2018. Available from: https://www.ismp.org/sites/default/files/attachments/2018-08/highAlert2018-Acute-Final.pdf .
3. Kementerian Kesehatan Republik Indonesia. Petunjuk Teknis Standar Pelayanan Kefarmasian di Rumah Sakit. 2019.
4. National Coordinating Council for Medication Error Reporting and Prevention. NCC MERP index for categorizing medication errors algorithm. 2001.
5. National Coordinating Council for Medication Error Reporting and Prevention. NCC MERP index for categorizing medication errors. 2022.
6. Nayak A, Katta H, Thunga G, Pai R, Khan S, Kulyadi GP. A critical analysis of labeling errors of high-alert medications–safety assessment and remedial measures through case-based approach. Clin Epidemiol Glob Health. 2022;18:101161.
7. Pristiyantoro W, S Wahyu K, Dona G. Evaluasi kesesuaian penyimpanan dan monitoring obat high alert medications di Instalasi Farmasi RSUD “X” Jakarta tahun 2023. Jurnal Pelayanan Kefarmasian. 2024;11.
8. Fahriati AR, Aulia G, Saragih TJ, Wijayanto DAW, Hotimah L. Evaluasi penyimpanan high alert medication di Instalasi Farmasi Rumah Sakit X Tangerang. Edu Masda Journal. 2021;5(2).
9. U.S. Department of Veterans Affairs, Veterans Health Administration, National Center for Patient Safety. Healthcare Failure Mode and Effect Analysis (HFMEA) guidebook. Available from: https://www.patientsafety.va.gov/docs/joe/Step-by-Step-Guidebook-HFMEA-January2021.pdf
10. World Health Organization. Medication without harm: WHO global patient safety challenge. 2017. Available from: https://www.who.int/publications/i/item/WHO-HIS-SDS-2017.6
11. World Health Organization. Patient safety: a competitive weapon in hospital management. Available from: https://cdn.who.int/media/docs/default-source/patient-safety/psirls/maldives/1.1-introduction-to-patient-safety.pdf