Insiden medication errors di RS X menunjukkan peningkatan terutama di unit farmasi meskipun sebagian besar termasuk kejadian nyaris cedera. Penelitian ini bertujuan untuk mengetahui gambaran insiden medication errors di unit farmasi RS X dan menganalisis hubungannya dengan faktor karakteristik individu, sifat dasar pekerjaan dan lingkungan organisasi serta manajemen. Desain penelitian menggunakan penelitian kualitatif dengan pendekatan studi kasus. Pengambilan data dilakukan melalui wawancara mendalam dan telaah dokumen dengan data kasus berdasarkan data sekunder laporan keselamatan pasien.Hasil penelitian menunjukkan program pencegahan dan tindak lanjut belum berjalan efektif dengan mayoritas insiden terjadi akibat kesalahan pembacaan resep dan ketidakpatuhan petugas menerapkan prosedur. Faktor penyebab lainnya adalah faktor pengalaman, kondisi overtime, penumpukan tugas, permasalahan komunikasi dan tidak adanya pelatihan kefarmasian. Dengan demikian perlunya peningkatan kepatuhan petugas dalam melaksanakan pekerjaan sesuai prosedur, merancang kembali sistem gateway, pengaturan jadwal kerja dan pelatihan terkait kefarmasian.

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Incidence medication errors in hospitals X is increasing especially in the pharmacy unit although most of them are nearmiss. The aim of this study is to describe the incidence of medication erros in pharmacy unit hospital X and analyze its relationship with individual characteristic, the nature of work and organizational environment and management factors. Design of this study is a case study qualitative research. Data collection was obtained through in-depth interviews and document review based on secondary data case report patient safety.The results showed prevention programs and follow-up incident had not been effective with the majority of errors occured due to the false-reading prescription and non-compliance officers in applying the procedure. Another contributing factors are experience factor, overtime, competing tasks, communication problems and lack of training of pharmacy. Thus it is needed to improve the compliance officer in carrying out the work according to procedures, redesigning the gateway system, setting work schedules and pharmacy training.