Intern
ati
o
n
a
l
Jo
urn
a
l
o
f
P
u
b
lic Hea
l
th Science (IJ
P
HS)
V
o
l.4
,
No
.2
,
Jun
e
2
015
, pp
. 11
9
~
12
3
I
S
SN
: 225
2-8
8
0
6
1
19
Jo
urn
a
l
h
o
me
pa
ge
: h
ttp
://iaesjo
u
r
na
l.com/
o
n
lin
e/ind
e
x.ph
p
/
IJPHS
Pharmaceutical Care Traini
ng Increases the Ability
Pharm
a
cists
to Reduce t
h
e Incid
e
nce of Medicati
on Error
Akr
o
m,
B
udiyon
o
, Wor
o
Su
padmi
Faculty
of
Phar
macy
, Univ
ersitas Ahmad Dahlan, Yog
y
ak
arta, I
ndonesia
Article Info
A
B
STRAC
T
Article histo
r
y:
Received Feb 10, 2015
Rev
i
sed
Ap
r
20
, 20
15
Accepted
May 16, 2015
The objective o
f
the stud
y
was
to
know
the potential
incid
e
nce of
medication
errors
before an
d after the tr
aini
ng of pharm
aceutic
al car
e in th
e Outpati
e
nt
Pharmacy
Unit of general privat hospital
in rur
a
l ar
ea of Yog
y
akarta. Th
e
observation
a
l studi used to describe
the pot
e
n
tial m
e
di
cat
io
n errors in
prescribing phas
e
and dispensing phase a
nd to det
e
rm
ine its com
p
letion
.
This
research
was co
nducted
prior
to
the tr
ain
i
ng of p
h
arm
aceut
i
c
a
l
ca
re th
at
is i
n
Ma
y
and af
ter t
h
e train
i
ng of pharm
aceut
i
c
a
l c
a
r
es that was in June 2014 at
the Outpa
t
i
e
nt
Unit of gen
e
ra
l
privat hospi
tal
i
n
rural
are
a
Yog
y
ak
art
a
.
The
data was tak
e
n from a book review of prescriptio
ns in outpatien
t
units for th
e
month. The res
u
lts showed that the
number of
potential medication
errors
before
the training of pharmaceutical
car
e in
pr
escribing
phase
(prescribing
errors) found 17 cases or 0.21%
and th
e dispensing phase (dispensing error)
as
m
a
n
y
as
36 cas
es
or 0.45%. W
h
ile the pot
ent
i
al for m
e
dic
a
tio
n errors
afte
r
the training phase of pharmaceutical ca
re in pr
escribing phas
e
(prescribin
g
error) is
found
as man
y
as 115
cases o
r
1
.
45
% and
the disp
ensing phase
(dispensing error
)
is found
as
man
y
as 165
cases
or 2.10%
.
Keyword:
M
e
di
cat
i
on Er
r
o
r
Pha
r
m
aceutica
l
Care
Pha
r
m
acist Int
e
rve
n
tio
ns
Training
Copyright ©
201
5 Institut
e
o
f
Ad
vanced
Engin
eer
ing and S
c
i
e
nce.
All rights re
se
rve
d
.
Co
rresp
ond
i
ng
Autho
r
:
Ak
rom
,
Depa
rt
m
e
nt
of
Pha
r
m
acol
ogy
and Clinical Pharm
acist,
Ph
arm
acy Fac
u
lty o
f
Un
iv
ersitas Ah
m
a
d
Dah
l
an
,
Jal
a
n P
r
o
f
.
D
r
.
Soe
pom
o, S
.
H
.
, Ja
nt
ura
n
,
W
a
r
u
n
g
bot
o,
Um
bul
ha
rj
o
5
5
6
1
2
,
Y
ogy
a
k
art
a
,
I
n
d
o
n
esi
a
.
Em
a
il : ak
m
a
a
_
u
a
d@yaho
o.co
.id
1.
INTRODUCTION
Med
i
catio
n
er
ro
r is on
e
of
cu
rr
en pub
lic health
pr
ob
lem
.
Self
m
e
d
i
cati
o
n or
ho
sp
ital dr
ug
u
s
i
ng
cont
ri
b
u
t
e
d t
o
m
e
di
cat
i
on er
ro
r i
n
c
o
m
m
u
n
i
t
y
. The
Nat
i
onal
C
o
or
di
na
t
i
ng C
o
u
n
ci
l
f
o
r
M
e
di
cat
i
o
n
Er
ro
r
R
e
po
rt
i
ng a
n
d
Preve
n
t
i
o
n (
N
C
C
M
E
R
P
) repo
rt
ed t
h
at
a
p
pr
o
x
i
m
at
el
y 0.1 m
i
l
l
i
on peo
p
l
e di
e ann
u
al
l
y
from
med
i
cal errors
th
at o
c
cu
r i
n
ho
sp
itals an
d
t
h
e resu
lting
d
e
ath
to
ll/year du
e to
m
e
d
i
catio
n
erro
rs is
h
i
gh
er th
an
that of
work pl
ace injuries [1]
.
Med
i
catio
n
erro
r is an
y life-
t
h
reat
e
n
i
n
g e
v
e
n
t
s
t
h
at
c
o
ul
d
be
pre
v
e
n
t
e
d.
Dat
a
m
e
di
cat
i
on e
r
r
o
r
eve
n
t
s
in
th
e world
co
n
tinu
e
to
in
crease. In
th
e
Un
ited
Stat
es, i
n
ci
de
nce o
f
m
e
di
cat
i
on er
r
o
r
s
bet
w
ee
n 2-
1
4
% o
f
patients with 1-2%
which
led to
a
l
o
ss of patients
us
ually
occurs
because
t
h
e
proces
s
of
prescri
b
ing is
wrong.
Medication e
r
ror is estim
a
t
ed to res
u
lt in
7,000 patients
die
each year in t
h
e US
[2]
.
The i
n
cide
nce
of m
e
dication
errors
in
Indonesia has
no
t b
e
en
record
ed
accu
rately and
sy
ste
m
atica
lly
b
u
t
m
e
d
i
catio
n
erro
rs are fairly co
mm
o
n
in
h
ealth
care in
stitu
tio
n
s
.
At th
e h
o
s
p
ital,
m
e
d
i
catio
n
erro
rs
rep
o
rt
e
d
3 t
o
6.
9% i
n
pat
i
e
n
t
s hos
pi
t
a
l
i
zed. The i
n
ci
den
c
e
of err
o
r
s
d
u
e t
o
err
o
rs i
n
d
r
ug
or
der al
so
vari
es
,
whi
c
h i
s
bet
w
e
e
n 0.
0
3
t
o
1
6
.
9
%. One
resear
cher f
o
un
d t
h
at
11% o
f
m
e
di
cat
i
on err
o
rs i
n
hos
pi
t
a
l
s
assoc
i
at
ed
wi
t
h
an er
ro
r
whe
n
s
ubm
i
t
ting t
h
e
dr
u
g
t
o
t
h
e pat
i
e
nt
i
n
t
h
e f
o
rm
of t
h
e dose
or t
h
e w
r
o
n
g
m
e
d
i
ci
ne.
Howev
e
r, d
e
spite th
e relativ
ely frequ
en
t m
e
d
i
catio
n
errors
are g
e
n
e
rally rare th
at en
d
e
d
with
an
inj
u
ry
in
th
e
pat
i
e
nt
s [
3
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
S
SN
:
2
252
-88
06
IJP
H
S V
o
l
.
4, No
. 2,
J
u
ne 2
0
1
5
:
11
9 – 1
2
3
12
0
Out
p
at
i
e
nt
u
n
i
t
(O
PU
) i
s
one
of t
h
e cr
uci
a
l
d
e
part
em
ent
of t
h
e
occu
rre
nce
of m
e
di
cat
i
on
err
o
rs
. It
i
s
because the pa
tient will use t
h
e m
e
dicine it
self and
with
out the supervision of health
workers,
as opposed
to
in
p
a
tien
t
wh
ere p
a
tien
t
s will b
e
m
o
n
ito
red
clo
s
ely in
o
r
d
e
r t
o
ach
iev
e
op
tim
a
l
th
erap
eu
tic pu
rpo
s
es.
Pha
r
m
aci
st
s as one
o
f
t
h
e
he
al
t
h
wo
r
k
ers
h
a
ve a st
rat
e
gi
c rol
e
i
n
a
d
dres
si
ng m
e
di
cat
i
on er
ro
rs, e
s
pec
i
al
l
y
rel
a
t
e
d t
o
pre
s
cri
b
i
n
g
an
d
di
spe
n
si
n
g
er
r
o
r
.
One
o
f
w
a
y
t
h
at
t
h
e
p
h
arm
aci
st
cont
ri
b
u
t
e
s i
s
by
doi
ng
a
pha
rm
aceutical care
[4].
Pha
r
m
aceutica
l
care is the r
e
sponsi
b
le provision
of
drug therapy for th
e purpose of achievi
ng
d
e
fi
n
ite o
u
t
comes th
at i
m
p
r
o
v
e
or m
a
in
tain
a p
a
tien
t
’s quality o
f
life (Weid
en
m
a
yer
et. all, 2
0
0
6
)
.
Gillesp
ie
(2012) states t
h
at patie
nts who ha
ve
received a c
o
m
p
re
he
nsive
pharm
acist interve
n
tion ha
ve
fewe
r
visits to
th
e ho
sp
ital an
d
can
sav
e
co
sts. Ph
arm
aci
st in
terv
en
tio
n also
sig
n
i
fican
tly i
m
p
r
o
v
e
s
th
e su
itab
ility
o
f
t
h
e
recipe [5].
The ability to i
m
ple
m
ent pharm
aceuti
cal
care requires
adequate kn
owledge of the
drug the
r
apy
goals
. It als
o
takes s
k
ill and a
high
willingne
ss to im
plem
ent them
. Screening
recipe as
one
part
of
pha
rm
aceutical care m
u
st be
im
ple
m
ented properly. T
h
e
r
efore
,
it is necessary to st
udy t
h
e potential of
med
i
catio
n
erro
rs th
at
o
ccur
in
g
e
n
e
ral privat h
o
s
p
ital
in
ru
ral area in Yo
g
y
ak
arta t
o
describ
e
t
h
e erro
r i
n
or
der t
o
d
o
pr
ope
r re
pai
r
. T
h
e pu
rp
ose
of t
h
i
s
st
udy
w
a
s t
o
det
e
rm
i
n
at
e the p
o
t
e
nt
i
a
l
of
m
e
di
cat
i
on er
ro
rs i
n
p
r
escr
ib
i
n
g
phase and
d
i
sp
en
sing
p
h
a
se in O
u
t
p
atien
t
g
e
n
e
r
a
l
p
r
i
v
at ho
sp
ital in
r
u
r
a
l ar
ea in
Y
ogyak
a
r
t
a
before
and a
f
ter the trai
ning
of ph
arm
aceutical care as well as to
determ
inate the proble
m so
lving relat
e
d to
m
e
di
cat
i
on er
r
o
r
.
2.
R
E
SEARC
H M
ETHOD
Th
is stud
y
was an
ob
serv
atio
n
a
l stud
y
w
ith
a sur
v
ey
m
e
th
o
d
. Th
i
s
stud
y w
a
s
co
ndu
cted
at
Ou
t
p
atien
t
of gen
e
ral
p
r
iv
at
ho
sp
ital in
rural area in
Y
o
gy
ak
art
a
, d
u
ri
ng M
a
y
and J
une
2
0
1
4
.
Th
e i
n
st
r
u
m
e
nt
s
use
d
in this
research we
re
form
review
of
presc
r
ip
tion
,
bo
ok
r
e
v
i
ew of
p
r
escr
ip
tion
an
d Fo
r
m
of
d
a
ta
pr
ocessi
ng
. Ob
ject
s were
wh
ol
e reci
pe o
f
t
h
e o
u
t
p
at
i
e
nt
gene
ral
pri
v
at
hos
pi
t
a
l
i
n
rur
a
l
area i
n
Yog
y
a
kart
a
i
n
M
a
y
an
d i
n
Jun
e
2
0
1
4
.
T
h
e co
urse
o
f
st
u
d
y
be
ga
n
by
co
nd
uct
i
n
g a
p
r
el
im
i
n
ary
st
udy
t
o
see
w
h
et
he
r
or
n
o
t
th
ere
was th
e
p
o
t
en
tial for
med
i
catio
n
erro
rs i
n
prescr
i
b
i
ng
pha
se an
d
di
spe
n
si
n
g
p
h
ase. T
h
e
n
, a
f
t
e
r t
h
e
o
b
t
ain
e
d
resu
lts, it fo
llo
wed
b
y
retriev
a
l of
p
r
i
o
r
d
a
ta to
the train
i
ng
(May 2
014
) and
after th
e trai
n
i
ng (Ju
n
e
2
014
).
The dat
a
de
ri
v
e
d fr
om
t
h
e for
m
revi
ew of p
r
escri
p
t
i
o
n an
d bo
o
k
revi
e
w
o
f
prescri
p
t
i
o
n i
n
Out
p
at
i
e
nt
g
e
n
e
r
a
l
p
r
i
v
at
h
o
s
p
ital in ru
ral ar
ea i
n
Y
ogyak
a
r
t
a.
Af
ter
th
e
d
a
ta w
a
s
ob
tain
ed th
en the d
a
ta
w
a
s p
e
rf
or
m
e
d
anal
si
si
s t
o
see
t
h
e p
o
t
e
nt
i
a
l
f
o
r m
e
di
cat
i
on
err
o
rs i
n
p
r
esc
r
i
b
i
n
g
phase
a
nd
di
s
p
ensi
ng
pha
se. F
u
rt
her
m
ore,
th
e pr
escr
i
b
ing ph
ase er
ro
r
s
w
e
r
e
gr
oup
ed
in
to
o
v
e
r
d
o
s
e, un
d
e
r
d
o
s
e, wr
ong
d
i
r
ectio
n, du
p
licatio
n,
w
r
o
n
g
du
rat
i
o
n o
f
t
r
e
a
tm
ent
,
cont
ra
i
ndi
cat
i
o
ns, i
n
di
cat
i
ons
wi
t
h
out
dr
u
g
s,
dr
u
g
s wi
t
h
o
u
t
i
n
d
i
cat
i
on, c
o
m
p
li
ance
pr
o
b
l
e
m
,
wro
n
g
pat
i
e
nt
, si
de
effect
s pot
e
n
t
i
a
l
,
dru
g
i
n
t
e
ract
i
ons
, wr
o
ng
of t
h
e st
re
ngt
hs d
o
sa
ge, wr
on
g
d
o
s
ag
e form
s a
n
d
d
r
ug
av
ailab
ility. Wh
ile t
h
e d
i
sp
en
si
ng
p
h
a
se errors were g
r
oup
ed
in
t
o
m
i
sread
th
e o
r
d
e
rs,
wr
on
g
pr
epa
r
a
t
i
on, a
n
d w
r
o
n
g
l
a
bel
e
. T
h
e
dat
a
wa
s o
b
t
a
i
n
ed t
h
en
p
r
e
s
ent
e
d
desc
ri
p
t
i
v
el
y
i
n
t
a
bl
es an
d
perce
n
t
a
ges
.
3.
R
E
SU
LTS AN
D ANA
LY
SIS
3.
1.
Prescribing E
rrors
3.
1.
1.
The Number
of Prescribing Errors
before
an
d after trai
ning
Tabl
e
1
pr
o
v
i
d
es i
n
f
o
rm
at
i
on t
h
at
t
h
e
det
ect
i
on
of
t
h
e
presc
r
i
p
t
i
o
ns
e
r
r
o
r
be
fo
re t
h
e t
r
ai
ni
n
g
o
f
pha
rm
aceutical care as m
u
ch as 17
recipes
or 0.21% a
nd
a
f
ter training of
pha
rm
aceuti
cal care as m
u
ch as 115
reci
pes o
r
1.
47
%.
Table
1.
Presc
r
ibing errors Be
fore a
n
d After
Training
Pha
r
maceutical Care at Outpatient
gene
ral
privat
h
o
s
p
ital in
rural area in Yog
y
ak
arta
Nu
m
b
er of
recip
e
Prescribing
error
Befor
e
T
r
aining
8068
17 (
0
.
21%)
After
T
r
aining
7847
115 (
1
.
47%)
Po
ten
tial m
e
d
i
catio
n
errors asso
ciated
with in
co
rrect p
r
es
cribin
g (
p
rescr
i
bing e
r
r
o
r) a
f
ter trainin
g
increase
d
m
o
re than 600%
. It can be cause
d as a
result of pharm
aceutical car
e training conducted by
Evaluation Warning : The document was created with Spire.PDF for Python.
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2-8
8
0
6
Pha
r
ma
ceu
tical Ca
re Tra
i
n
i
ng
In
crea
ses th
e Ab
ility Pha
r
ma
cists to
Redu
ce th
e
In
ci
d
e
n
c
e .... (Akro
m
)
12
1
Pha
r
m
acis
t
De
partem
ent. So
pha
rm
acists increased a
w
are
n
ess or
c
o
ncern for
t
h
e pre
v
ent
i
o
n
of
m
e
dicat
i
o
n
erro
rs and
un
derstand
h
o
w t
o
id
en
tify relev
a
n
t
po
ten
tia
l m
e
d
i
catio
n
errors
th
at can
resu
lt in
treatm
e
n
t
failu
re.
3.
1.
2.
Types
of Pres
cribing Err
o
r
s
Tabl
e 2
descr
i
bes t
h
e m
o
st
pot
e
n
t
i
a
l
err
o
rs t
h
at
can
be i
d
e
n
t
i
f
i
e
d
by
p
h
arm
aci
st bef
o
re t
h
e
pha
rm
aceutical care trai
ning i
s
overdose.
Tabl
e
2. Ty
pe
of
Pres
cri
b
i
n
g
err
o
r
be
fo
re a
n
d a
f
t
e
r
pha
rm
aceut
i
cal
care t
r
ai
ni
ng
at
O
u
t
p
at
i
e
nt
ge
neral
pri
v
at
h
o
s
p
ital in
rural area in Yog
y
ak
arta
Type of Error
Nu
m
b
er Er
ror
Before Training
After
Training
Duplication
1 (
5
.
88%)
26 (
22.
61%)
Co
m
p
liance pr
oblem
’s
0 (
0
%)
17 (
14.
78%)
W
r
ong Dir
e
ction
2 (
11.
76%)
14 (
12.
17%)
Under
dose
3 (
17.
65%)
11 (
9
.
57%)
Over
dose
7 (
41.
18%)
9 (
7
.
83%)
I
ndications withou
t dr
ugs
0 (
0
%)
8 (
6
.
96%)
Adver
s
e dr
ugs r
e
action
0 (
0
%)
8 (
6
.
96%)
Dr
ug I
n
ter
action
0 (
0
%)
7 (
6
.
09%)
W
r
ong Dur
a
tion
0 (
0
%)
5 (
4
.
35%)
Str
e
nghts Form
ulation
0 (
0
%)
3 (
2
.
61%)
Dosage form
0 (
0
%)
3 (
2
.
61%)
Contr
a
indications
2 (
11.
76%)
2 (
1
.
74%)
W
r
ong Patients
1 (
5
.
88%)
1 (
0
.
87%)
Availability
0 (0%)
1 (0.87%)
Dr
ugs without indi
cation
1 (
5
.
88%)
0 (
0
%)
T
o
tal err
o
r
17 (
100%)
115 (
100%)
For e
x
am
ple, patients with skin
infections cause
d by
traffic accidents get pres
cription ora
l
cip
r
o
f
lox
aci
n
50
0 m
g
, 1
tab
l
et
q2
4h
r
;
as know
ed th
at a
d
o
se o
f
or
al cipr
oflo
x
acin is 250
m
g
-
5
0
0
m
g
q1
2hr
.
Som
e
types of errors
before training of
pha
rm
aceuti
cal care is not found suc
h
com
p
liance proble
m
’
s,
indications without drug,
a
dverse drug
react
ion, interactions,
duration, st
rengths
form
ulation,
dosa
ge form
,
an
d
th
e av
ailab
ility o
f
d
r
u
g
s
. Th
e ab
sen
ce
o
f
fi
n
d
i
n
g
s of
th
e erro
r can
be cau
sed
b
y
lack
of kn
owledg
e of
pha
rm
aci
st
. Whi
l
e
aft
e
r t
h
e t
r
ai
ni
n
g
,
det
ect
i
on
of
p
o
t
e
nt
i
a
l
presc
r
i
b
i
ng e
r
ro
rs are m
o
st
dr
u
g
d
u
p
l
i
cat
ion t
h
at
occurre
d in
26 cases. Duplication occ
u
red
because the
pa
tient is still ha
d m
e
dicine at hom
e, but
given the
sam
e
dru
g
.
It
was
ot
he
rwi
s
e
i
d
ent
i
f
i
e
d
by
p
h
arm
aci
st
s and
o
v
erc
o
m
e
so c
oul
d l
e
a
d
t
o
pa
t
i
e
nt
s usi
n
g
t
h
e
sam
e
d
r
ug
s th
at
result in
ov
erdo
se.
Precri
b
i
n
g e
r
r
o
r
i
s
m
o
st
co
m
m
on i
n
m
e
di
cat
i
on e
r
r
o
r incid
e
n
ce i
n
ou
t p
a
tien
t
s
ho
sp
i
t
al in
pu
b
lic
h
o
s
p
ital,
in Yo
g
y
ak
arta [4
].
M
e
di
cat
i
o
n
e
r
r
o
rs
h
a
ve
bee
n
c
o
ncept
u
al
i
zed
base
d
o
n
c
a
uses,
out
c
o
m
e
s, a
n
d
st
ages o
f
t
h
e
m
e
di
cat
i
on del
i
very
p
r
oce
ss.
R
e
search s
h
ow
s t
h
at
pre
s
cri
b
i
ng e
r
r
o
rs ha
ve
cont
ri
b
u
t
e
d t
h
e
m
o
st
in
th
e
o
c
cu
rrence of erro
rs,
wh
ich
is 39
%
due to
lack
of
k
n
o
wl
e
dge
ab
o
u
t
p
r
escri
b
ed
m
e
di
cat
i
ons
, l
e
ss
bui
l
d
rel
a
t
i
ons
hi
ps
w
i
t
h
pat
i
e
nt
s, sl
i
p
s, o
r
m
i
scal
cu
l
a
t
i
on. Tra
n
scr
i
pt
i
on an
d ve
ri
fi
cat
i
on t
a
ke 1
2
% o
f
t
h
e err
o
rs are
main
ly d
u
e
t
o
th
e in
ab
ility to
read
th
e reci
pe. Miscalcu
latio
n, m
i
stak
e p
r
ep
aration
,
and
d
i
stribu
tio
n
o
f
erro
rs
cont
ri
b
u
t
e
t
o
t
h
e 1
1
% er
ro
r fo
r di
s
p
ensi
ng
phase
. A
nd f
i
nal
l
y
, 38% er
ro
r occ
u
r
r
ed i
n
t
h
e adm
i
ni
strat
i
o
n
p
h
a
se, wh
ich
is cau
sed
m
a
in
l
y
d
u
e
to
th
e similar p
ack
ag
ing
,
re-ch
e
ck
fai
l
u
r
e, th
e failure to
u
n
d
e
rstand
th
e
drug dose,
dire
ction of treatment is
not clear, and the s
h
orta
ge of officers[
7]. A study in
a teaching
hos
p
ital in
M
a
l
a
y
s
i
a
t
o
pr
ovi
de dat
a
t
h
at
from
ent
e
ri
ng
out
pat
i
e
nt
pre
s
cri
p
t
i
o
n am
ount
s t
o
6
3
4
0
f
o
r
one wee
k
, t
h
e
r
e are
43 reci
pes t
h
at re
quire
pha
rmaceutical intervention is pr
oble
m
a
tic due to
the reci
pe. The
problem
consi
s
ts of
co
m
p
leten
e
ss
pr
escr
i
p
tio
n, w
r
o
n
g
dr
ug
,
wr
ong
d
o
s
e,
and
w
r
o
n
g
po
ten
tial
dr
ug
.
3.
2.
Dispensin
g
Er
ror
Dispe
n
sing e
r
rors
are t
h
e
faul
t of t
h
e
officer at
th
e
tim
e
o
f
th
e
read
ing
p
r
escrip
tion
(m
isr
ead
o
r
d
e
r),
d
r
ug
prep
aratio
n, and
lab
e
ling
/ d
r
ug
etiq
u
e
tte. It will
cau
se erro
rs in
d
i
spen
sing
m
e
d
i
cat
io
n
erro
rs, wh
ich
i
n
tu
rn
can
lead to
treatm
e
n
t
failu
re
.
Here i
s
t
h
e
im
port
a
nce
of
di
spe
n
si
n
g
m
e
di
cat
i
on
p
r
o
p
e
r
l
y
.
Table
3
desc
ribes t
h
e m
o
st identification of
pote
n
tially me
dication
errors
by
pha
rm
aceutical services
(
d
isp
e
nsing
er
ro
r)
.
D
i
sp
en
cing
er
ror
b
e
for
e
tr
ain
i
ng
w
e
r
e
as
m
u
ch as 36 c
a
ses or
0.
45%
and a
f
t
e
r t
h
e t
r
ai
ni
n
g
were as m
u
ch as 165 cases
or
2.10%. An ave
r
a
g
e
eve
r
y day there
were
3 cases
th
at th
e po
tential for
di
spe
n
si
n
g
e
r
r
o
rs f
o
un
d
by
t
h
e
p
h
arm
aci
st
.
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06
IJP
H
S V
o
l
.
4, No
. 2,
J
u
ne 2
0
1
5
:
11
9 – 1
2
3
12
2
Table
3.
Dispe
n
sing e
r
rors Be
fore a
n
d After
Training
Pha
r
maceutical Care at Outpatient
gene
ral
privat
h
o
s
p
ital in
rural area in Yog
y
ak
arta
Nu
m
b
er of
recip
e
Prescribing
error
Befor
e
T
r
aining
8068
36 (
0
.
45%)
After
T
r
aining
7847
165 (
2
.
10%)
It is seen
th
e in
creasing
i
d
en
tificatio
n
o
f
p
o
t
en
tial d
i
sp
ensing
error
in
cid
e
n
c
e b
e
cau
s
e
o
f
the
increase
d
a
w
areness
of the
pharm
acis
t
i
n
u
n
d
erst
a
ndi
ng
t
h
e p
o
t
e
nt
i
a
l
of
m
e
di
cat
i
on er
r
o
rs
t
h
at
c
oul
d
occu
r i
n
the pha
rm
aceutical service. This coul
d be
due to increa
se
d awa
r
enes
s of
the effects of pha
rm
aceutical care
train
i
ng
th
at
were fo
llow
e
d by a ph
ar
m
acist.
3.
2.
2.
Types
of Dis
p
ensing Err
o
rs
Tabl
e 4
descri
bes t
h
at
t
h
e m
o
st
fi
n
d
i
n
gs
of
event
s
t
h
at
c
o
ul
d
pot
e
n
t
i
a
l
l
y
cause a di
s
p
e
n
si
n
g
er
ro
r
bef
o
re
t
r
ai
ni
ng
i
s
p
r
epa
r
at
i
o
n
of
t
h
e
dr
u
g
that
is as m
a
ny as
19 cases
or
52.78%.
Table
4. Ty
pes
of
dispe
n
sing
error be
fore a
n
d a
f
ter tr
ai
ning Pha
r
m
aceutica
l
Care at Out
p
a
tient general
privat
h
o
s
p
ital in
rural area in Yog
y
ak
arta
Type Error
Nu
m
b
er
Befo
re th
e tra
i
ni
n
g
After
the
tra
i
ning
M
i
sr
eading
9 (
25.
00%)
31 (
18.
79%)
Pr
epar
ation
19 (
52.
78%)
52 (
31.
52%)
L
a
beling
8 (
22.
22%)
82 (
49.
70%)
T
o
tal err
o
r
36(
100%)
165 (
100%)
Whi
l
e
aft
e
r t
h
e
t
r
ai
ni
ng
, t
h
e t
y
pe of er
ro
r w
h
i
c
h wa
s
m
o
st
com
m
onl
y
fou
nd
was 8
2
case
s
or 4
9
.
7
0%
in the la
beling. For exam
ple, patient
s recei
ved
a novom
i
x recipe (ins
ul
in
m
i
xture)
t
h
en were
rea
d
by
the
p
h
a
r
m
acist as n
ovo
r
a
p
i
d (f
ast actio
n
of
in
su
lin
).
I
f
t
h
is
w
a
s
no
t ob
serv
ed pro
p
e
r
l
y,
it w
o
u
l
d cause v
e
r
y
h
a
r
m
f
u
l eff
ects wh
er
e
n
ovo
rap
i
d
w
a
s rap
i
dly actin
g
in
su
l
i
n
po
st pr
an
d
i
al w
h
ile nov
omix
w
a
s a m
i
x
t
ur
e of
in
su
lin u
s
ed
t
o
treat po
st-p
rand
ial g
l
u
c
o
s
e and
fastin
g g
l
u
c
ose.
3.
2.
3.
Com
p
letio
n
of
Po
ten
t
ial Me
dicati
on
err
or
Tabl
e 5
desc
r
i
bed t
h
e i
n
t
e
r
v
ent
i
o
n
by
p
h
a
rm
aci
st
s i
n
resol
v
i
ng
pr
o
b
l
e
m
s
associ
at
ed wi
t
h
t
h
e
pot
e
n
t
i
a
l
of
m
e
di
cat
i
on
er
ro
rs
bef
o
re
t
h
e t
r
ai
n
i
ng
o
f
pha
rm
ac
eutical care
wa
s a way to
con
f
irm
to
th
e do
cto
r
.
Table 5. Pha
r
macist
Interv
e
n
tion for Potential Before
a
n
d After T
r
aini
ng Pharm
aceutical Care at Outpati
e
nt
g
e
n
e
ral
p
r
ivat
h
o
s
p
ital in
rural area in Yog
y
ak
arta
Types of Interven
tion
Nu
m
b
er
Before The T
r
aining
After
The Traini
ng
Confirm
a
tion to the doctor
17 (
100%)
66 (
57.
39%)
I
n
form
ation and Education
0 (
0
%)
41 (
35.
65%)
Counselin
g
0 (
0
%)
3 (
2
.
61%)
Other
inter
v
entions
0 (
0
%)
5 (
4
.
35%)
T
o
tals
17 (
100%)
115 (
100%)
Wh
ile after t
h
e train
i
ng
, ph
armacist in
terv
en
tio
ns
in
addressin
g
po
ten
tial
m
e
d
i
catio
n
errors were to
con
f
i
r
m
t
o
t
h
e
do
ct
or
wi
t
h
a
num
ber
of
6
6
cases (
5
7.
39
%), i
n
f
o
rm
at
i
on a
nd e
d
ucat
i
o
n
41 ca
ses (
3
5
.
6
5
%)
,
cou
n
sel
i
n
g
3
cases (
2
.
6
1 %
)
an
d
ot
h
e
r i
n
t
e
rve
n
t
i
ons
as m
u
ch
as 5 cases (4
.3
5%). Oth
e
r in
terv
en
tio
ns
conducted
among ca
ncele
d
t
h
era
p
y fro
m
a d
o
ct
o
r
but
we
re
not
wi
t
h
c
o
nfi
r
m
a
t
i
on. C
a
ncel
l
a
t
i
on t
h
er
apy
o
r
chan
gee
d
o
f
d
o
s
es sh
oul
d n
o
t
be m
a
de uni
l
a
t
e
ral
l
y
by
t
h
e pharm
aci
st
as p
o
ssi
bl
e t
o
t
h
e
d
o
ct
o
r
t
o
ha
ve a
not
her
pu
r
pose
.
P
h
a
r
m
aci
st
supp
ose
d
t
h
e
d
o
ct
o
r
t
o
con
f
i
r
m
t
h
at
t
h
e p
r
o
b
l
e
m
coul
d
be s
o
l
v
e
d
t
o
g
e
t
h
er.
The results showe
d
that t
h
e
pha
rm
aceutical care tr
aining inc
r
eases the ab
ility of pharm
acists to
pre
v
e
n
t
i
ng t
h
e
i
n
ci
dence
of
m
e
di
cat
i
on err
o
rs i
n
one
of
t
h
e priv
ate ho
sp
itals in
rural
areas in Yogy
akarta.
Pha
r
m
aceutica
l
care training
is prove
n
to increase the abil
ity of pha
rm
ac
is
ts in identifying the inci
dence of
m
e
di
cat
i
on er
r
o
rs ei
t
h
e
r
i
n
p
r
escri
b
i
n
g
pha
s
e
or
di
spe
n
si
ng
ph
ase. Ph
armacist in
terv
en
tio
ns related
p
o
t
en
tial
Evaluation Warning : The document was created with Spire.PDF for Python.
I
J
PH
S I
S
SN
:
225
2-8
8
0
6
Pha
r
ma
ceu
tical Ca
re Tra
i
n
i
ng
In
crea
ses th
e Ab
ility Pha
r
ma
cists to
Redu
ce th
e
In
ci
d
e
n
c
e .... (Akro
m
)
12
3
medication errors
be
fore the
pha
rm
aceu
tical care traini
ng
were
by way to co
nfirm
to the doct
o
r
while after the
pha
rm
aceutical care training
were by way
of confirm
a
tio
n
to the doct
o
r, the provisi
on of drug information
and
pat
i
e
nt
e
d
ucat
i
o
n
,
m
e
di
cat
i
on c
o
u
n
sel
i
ng
an
d act
i
v
i
t
i
e
s /
ot
he
r i
n
t
e
rve
n
t
i
o
ns.
A
m
e
di
cat
i
on ca
n
be a
b
l
essing
if th
e
h
ealth
care prov
id
er
presc
r
i
b
e
s
, di
s
p
e
n
ses a
n
d a
d
m
i
ni
st
ers d
r
u
g
s t
o
pat
i
e
nt
s
co
rrect
l
y
[
8
]
.
4.
CO
NCL
USI
O
N
Po
ten
tial Medicatio
n
errors in
p
r
escrib
i
n
g ph
as
e
(p
rescr
i
b
i
ng
er
ror
)
b
e
for
e
th
e tr
ain
i
ng
of
pha
rm
aceutical care were found in
17 cases
or 0.21% and
after the training we
re found as
m
a
ny as in 115
cases or
1.
45
%. Pot
e
nt
i
a
l
m
e
di
cat
i
on err
o
rs i
n
di
spe
n
s
i
ng p
h
ase
(di
s
pe
nsi
n
g err
o
r
)
bef
o
re t
r
ai
ni
ng
o
f
pha
rm
aceutical care
we
re
found as m
a
ny as
in 36 cases
or
0.45% a
n
d afte
r the
traini
ng
were
found as
many
as i
n
1
65 case
s
or
2.
10
%. C
o
m
p
l
e
t
i
on of t
h
e p
r
o
b
l
e
m
s
as
sociated wit
h
medication errors
before the
training
was b
y
way o
f
co
nfirm
a
tio
n
to
th
e
d
o
c
t
o
r
wh
ile after th
e t
r
ai
ni
ng
wer
e
by
way
of c
o
nfi
r
m
a
t
i
on t
o
t
h
e d
o
ct
o
r
,
gi
vi
n
g
i
n
f
o
rm
at
i
on &
pat
i
e
nt
educat
i
o
n,
p
a
t
i
e
nt
co
u
n
sel
i
n
g
and
ot
her
i
n
t
e
r
v
ent
i
o
ns
.
5.
RECO
ME
ND
ATIO
N
Fr
o
m
th
e r
e
su
l
t
s o
f
t
h
is study co
u
l
d
b
e
u
s
ed
as a
r
e
f
e
r
e
nce th
at th
e
n
e
ed
for
ph
ar
m
a
c
e
u
tical car
e
train
i
ng
for
p
h
arm
acis
t
s in
hosp
itals to
red
u
c
e
t
h
e i
n
ci
de
nce
o
f
m
e
di
cat
i
on
err
o
rs
.
ACKNOWLE
DGE
M
ENTS
Ack
n
o
wl
e
dge
m
e
nt
s and a
w
a
r
ds
gr
ant
e
d t
o
di
rect
o
r
s a
nd
m
e
di
cal
st
aff at
R
S
U PK
U M
uham
m
adi
y
ah
Yo
gy
aka
r
t
a
. T
h
ey
ha
ve
gi
ve
n
pe
rm
i
ssi
on so
t
h
at
resea
r
ch
c
a
n
be
do
ne.
REFERE
NC
ES
[1]
National Coordinating Council for Medi
cation Error Reporting and Prevention,
“Medication erro
rs”, 2014. From
http://www.nccmerp.org/ [Janu
a
r
y
6, 2014)
[2]
Dwiprahasto I.,
“Interventions Training
to Minimize Risk
of
Medication errors in
Prim
ar
y
He
al
th Care C
e
nt
er”
,
Journal of Medical Sciences
, vol/issue: XXXVIII
(1), 2006. From: http: //i-
lib
.ugm
.ac.id
/jurnal/detail .php
?
dataId =
5603 [Januar
y
6, 2014]
[3]
William
s
DGT.,
“Medication
err
o
rs”, JR Co
l
l
Ph
y
s
icians
Edinb,
pp. 343-346
, 20
07.
[4]
Perwitasari D., Jamiul A., Wah
y
unings
ih I., “Medication erro
r In Out
patients of government hospital in
Yog
y
ak
arta
”,
In
ternational Jour
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,
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E
ffect of Clini
c
a
l
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h
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i
K
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pot CS
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li M
N
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utpa
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ach
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la
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[7]
Shah A.,
“
P
harm
ac
y In
terv
ention
in m
e
dication-us
e process”, the
University
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Manitob
a
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e
g, C
a
nad
a
, 201
0.
[8]
W
i
edenm
a
yer K
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u
m
m
e
rs
RS
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ackie CA.
,
Go
us
AGS
., Everar
d M
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p D.,
“
D
eveloping ph
arm
a
c
y
pra
c
ti
ce:
A focus on patient car
e Handboo
k- 2006 edition
”
, World Health
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r
ganization
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a
rtm
e
nt of Medi
cines Policy
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e
n
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.
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