REDESIGN PELAYANAN FARMASI DENGAN METODE FAILURE MODE AND EFFECT ANALYSIS

Abstract

Background: Pharmacy service is a high risk area in the
support of health service quality. PKU Muhammadiyah Hospital
is a hospital that respons to systematic movement in services
that focus on patient safety such as minimizing the incidence
of medication error that often happens. This condition requires
new design that can minimize risk for the incidence of medication
errorr by implementing Failure Mode and Effect Analysis (FMEA)
method as a systematic and proactive method that improves
quality of hospital service.
Objective: To design new service quality at PKU
Muhammadiyah Hospital Yogyakarta by identifying risk for
medication error in the process of drug use, factors that can
induce the incidence of medication error in the process drug
use and make new design that can minimize risk for medication
error of PKU Muhammadiyah Hospital Yogyakarta.
Method: This study used action research. This design was
chosen to involve subject of the study more actively in doing the
redesign of pharmacy service using FMEA method to minimize
risk for the incidence of medication error. Subject of the study
were all incidents of medication error in the process of drug use
including related health staff involved in the process of drug
use. Primary were data obtained from indepth interview, group
discussion, focuses group discussion, and workshop.
Result: Failure Mode and Effect Analysis (FMEA) method was
expected to minimize errors in drug use system at outpatient
pharmacy service at PKU Muhammadiyah Hospital Yogyakarta.
Through FMEA method it was identified that the highest Risk
Priority Number (RPN) was failure in confirmation with doctors
(294), failure in identifying drug name (216). In this study new
designs proposed as pilot project were change of layout of
drug identification color sticker according to therapy class; the
determination of standard operating procedure of
communication with doctors giving prescription, confirmation
with doctors for non cito prescription and procedure of
implementation of outpatient pharmacy service supervision.
Trial of layout of drug identification color sticker was carried
because it did not need high cost and was relatively easy to
socialize and do. The result of evaluation after new design
intervention was declining value of RPN for failure in
communication with doctors (from 294 to 196) and failure in
identifying drug name (from 216 to 144).
Conclusion: The new design implemented was relatively
effective in minimizing errors in identifying drug name and
minimizing failure in communication with doctors.
Keywords: medication error, failure mode and effect analysis,
redesign