Prospective Identification of Medication Error Incidents During the Dispensing Stage of High-Alert Medications in the Emergency Department (ED) of Fatmawati Central General Hospital for the November 2025 Period
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Abstract
Medication errors involving high-alert medications in the emergency department (ED) have the potential to cause serious harm, making early identification during the dispensing stage essential. This study aims to describe potential medication errors related to the storage, distribution, and use of high-alert medications in the ED Pharmacy Depot and emergency trolleys at Fatmawati Central General Hospital. A prospective observational study was conducted in November 2025 through direct observation of the dispensing process, evaluation of emergency trolleys, and interviews with nurses who administer high-alert medications. Incidents were classified using an adapted NCC MERP Index. Seven discrepancies were identified, all of which involved the absence of “high-alert” labels on medication packaging and shelving, as well as limited sticker availability; these discrepancies were categorized as level 1 (potential error without harm). Nurses demonstrated good knowledge of high-alert medications, but were not sufficiently attentive to missing labels. These findings highlight the need for standardized labeling, adequate sticker supply, and routine audits to strengthen patient safety in the ED.
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References
2. Guntschnig, S., Barbosa, R., Jenzer, H., Greening, M., Hayde, J., Heery, H., Serrano, M. C. I., Lajtmanová, K., Rossin, E., Tentova-Peceva, S., Kohl, S., & Mulac, A. (2025). Tackling medication errors: how a systems approach improves patient safety. European Journal of Hospital Pharmacy, ejhpharm-2025. https://doi.org/10.1136/ejhpharm-2025-004533
3. Institute for Safe Medication Practices. (2018). ISMP List of High-Alert Medications in Acute Care Settings. Retrieved from https://www.ismp.org/sites/default/files/attachments/2018-08/highAlert2018-Acute-Final.pdf
4. Institute for Safe Medication Practices. (2018). ISMP List of High-Alert Medications in Acute Care Settings Updated for 2024. Retrieved from https://www.ismp.org/sites/default/files/attachments/2024-01/20240111.pdf
5. Kementerian Kesehatan Republik Indonesia. (2019). Petunjuk Teknis Standar Pelayanan Kefarmasian di Rumah Sakit
6. Kementerian Kesehatan Republik Indonesia. (2016). Peraturan Menteri Kesehatan Nomor 72 Tahun 2016 tentang Standar Pelayanan Kefarmasian di Rumah Sakit. Kemenkes RI.
7. Kementerian Kesehatan Republik Indonesia. (2021). Keputusan Menteri Kesehatan Nomor HK.01.07/MENKES/4799/2021 tentang Daftar Obat Keadaan Darurat. Jakarta: Kemenkes RI.
8. Kharisma, L. (2022). Penanganan obat-obat high-alert di fasilitas pelayanan kesehatan. STIKes Bina Cipta Medika Repository. https://repository.stikesbcm.ac.id/id/eprint/244/
9. Khoury, R., et al. (2024). Prevalence of medication errors in the emergency department: A systematic review and meta-analysis. International Journal of Clinical Pharmacy. https://doi.org/10.1007/s11096-024-01742-w
10. National Coordinating Council for Medication Error Reporting and Prevention. (2022). NCC MERP Index for Categorizing Medication Errors.
11. Nayak, A., Katta, H., Thunga, G., Pai, R., Khan, S., & Kulyadi, G. P. (2022). A critical analysis of labeling errors of high-alert medications – Safety assessment and remedial measures through case based approach. Clinical Epidemiology and Global Health, 18, 101161. https://doi.org/10.1016/j.cegh.2022.101161
12. Tariq, R. A., Vashisht, R., Sinha, A., & Scherbak, Y. (2024). Medication Dispensing Errors and Prevention. In StatPearls. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK519065/
13. Thomas, D., Westbrook, J., & Baysari, M. (2021). Medication safety in emergency departments: Challenges and opportunities. BMJ Quality & Safety, 30(5), 367–375.
14. Um, I. S., Clough, A., & Tan, E. C. (2023). Dispensing error rates in pharmacy: A systematic review and meta-analysis. Research in Social and Administrative Pharmacy, 20(1), 1–9. https://doi.org/10.1016/j.sapharm.2023.10.003
15. World Health Organization. (2019). Medication safety in high-risk situations. WHO. https://www.who.int/publications/i/item/WHO-UHC-SDS-2019.11
16. World Health Organization. (2024). Medication Without Harm initiative update. WHO. https://www.who.int/initiatives/medication-without-harm
17. World Health Organization. (n.d.). Patient Safety: A Competitive Weapon in Hospital Management. Retrieved from https://cdn.who.int/media/docs/default-source/patient-safety/psirls/maldives/1.1-introduction-to-patient-safety.pdf
18. World Health Organization. (n.d.). WHO Model Lists of Essential Medicines. Retrieved from https://www.who.int/groups/expert-committee-on-selection-and-use-of-essential-medicines/essential-medicines-lists