• ANDIKA DWI MAHENDRA Department of Pharmacy, dr Soeradji Tirtonegoro General Hospital Medical Center, Klaten, Indonesia


Objective: Medication error is the most common errors in a hospital setting and a serious issue that intimidate the safety of the patient and may cause mortality and morbidity. The aim of this study is to explore the rate of medication errors reporting in an Indonesian hospital.

Methods: This study is retrospective and descriptive. This research was conducted at dr. Soeradji Tirtonegoro General Hospital Medical Center from January to June 2020. Medication error reporting, which was reported for six months, was the sample of the study.

Results: On the period, 105,171 prescribing sheets were collected. 9.5% of the total prescribing sheets are categorized as Medication Error (ME). The highest incident of ME was prescribing error (88.24%), then followed by transcribing error (7.61%), dispensing error (4.02%), and the last was administration error (0.13%).

Conclusion: The most common incident occurred at prescribing stage because the hospital is not supported by electronic prescription. Medication error is an inevitable event during the medication process. But, the incidents can be minimized by implementing some preventive strategies to improve patient safety and safe drug use.

Keywords: Medication error, Medication error incident, Pharmacy service, Prescribing error, Indonesian hospital


1. American Society of Hospital Pharmacists. ASHP Statement on pharmaceutical care. Am J Hosp Pharm 1993;50:1720–3.
2. Sreelalitha N, Vigneshwaran E, Narayana G, Reddy YP, Reddy MR. Review of pharmaceutical care services provided by the pharmacists. Int Res J Pharm 2012;3:78–9.
3. Hepler CD, Strand LM. Opportunities and responsibilities in pharmaceutical care. Am J Health-System Pharm 1990;47:533–43.
4. To Err Is Human: Building a Safer Health System. Washington DC. National Academies Press; 2000. Available from: [Last accessed on 04 Feb 2021]
5. Ulfah SS, Mita SR. Review Artikel: medication errors pada tahap prescribing, transcribing, dispensing dan administering. Farmaka 2017;15:8.
6. Fauziyah S, Nur A, Azrifitria A. The impact of pharmacists’ interventions to prevent medication errors at a tertiary hospital in central Jakarta, Indonesia. Pharm Biomed Sci J 2019;1:1–6.
7. Dwiprahasto I. Intervensi pelatihan untuk meminimalkan resiko medication error di pusat pelayanan kesehatan primer. Berkala Ilmu Kedokteran 2006;38:1–8.
8. Mutmainah N. Kajian medication error pada kasus stroke di rs x surakarta tahun 2004. J Farmasi Indonesia 2008;4:42–6.
9. Nurfitria RS, Effendi RNA, Iskandar D. Potential medication errors in electronic prescribing in a primary health care. Indonesian J Pharm Clin Res 2019;02:45–54.
10. Perwitasari DA, Abror J, Wahyuningsih I. Medication errors in outpatients of a government hospital in Yogyakarta Indonesia. Int J Pharm Sci Rev Res 2010;1:8–10.
11. Ernawati DK, Lee YP, Hughes JD. Nature and frequency of medication errors in a geriatric ward: an Indonesian experience. Ther Clin Risk Management 2014;10:413–21.
12. Food and Drug Administration. Working to Reduce Medication Errors. Working to Reduce Medication Errors; 2019. Available from: [Last accessed on 12 Feb 2021]
13. Sergeevna SM, Efimovna LE. Improving training of pharmaceutical specialists for consultation in pharmacy organizations using interactive forms of education. Pharmacophore 2020;11:7–14.
14. Kenawy AS, Kett V. The impact of electronic prescription on reducing medication errors in an Egyptian outpatient clinic. Int J Med Informatics 2019;127:80–7.
15. Shawahna R, Abbas A, Ghanem A. Medication transcription errors in hospitalized patient settings: a consensual study in the Palestinian nursing practice. BMC Health Serv Res 2019;19:644.
16. Al-Shara M. Factors contributing to medication errors in jordan: a nursing perspective. Iran J Nurs Midwifery Res 2010;16:1-4.
17. Salmasi S, Khan TM, Hong YH, Ming LC, Wong TW. Medication errors in the Southeast Asian countries: a systematic review. Fuh JL. editor. PLoS One 2015;10:1–19.
18. Allen LV. The art, science, and technology of pharmaceutical compounding. Fifth edition. Washington DC: American Pharmacists Association; 2016. p. 699.
19. Aldhwaihi K, Umaru N, Pezzolesi C, Schifano F. A systematic review of the nature of dispensing errors in hospital pharmacies. IPRP 2016;5:1–10.
20. Campmans Z, Van Rhijn A, Dull RM, Santen Reestman J, Taxis K, Borgsteede SD. Preventing dispensing errors by alerting for drug confusions in the pharmacy information system-a survey of users. PLOS One 2018;13:1–11.
21. Agency for Healthcare Research and Quality. Medication administration errors. Patient Safety Network; 2019. Available from: [Last accessed on 09 Feb 2021]
22. Konuru V, Adepu R. A study on medication administration errors in a tertiary care hospital. Indian J Pharm Practice 2011;4:37–42.
23. Azrifitria A, Fauziyah S, Apriliana N. The impact of pharmacists’ interventions prevent medication errors at a tertiary hospital in central Jakarta, Indonesia. Pharm Biomed Sci J 2019;1:1–6.
47 Views | 57 Downloads
How to Cite
MAHENDRA, A. D. “THE NATURAL AND PREVALENCE OF MEDICATION ERRORS IN A TERTIARY HOSPITAL IN INDONESIA”. International Journal of Current Pharmaceutical Research, Vol. 13, no. 3, May 2021, pp. 55-58, doi:10.22159/ijcpr.2021v13i3.42096.
Original Article(s)