Risk Assessment Analysis of Medication Error Incidents from Public Health Center in Tangerang City, Indonesia: A Cross-Sectional Study

Background: Unsafe health care has been recognized as a global challenge, which ensures that safe medication practices lead to solving these challenges. The implementation of these practices is becoming an essential factor to be applied in primary health care in Indonesia. This study aimed to analyze and explore the root cause of medication error incidents reported internally at one of the public health centers in Tangerang City, Indonesia. Methods: This descriptive study was conducted utilizing 41 internal reports of medication error incidents in 2023 extracted from the patient safety committee system. The data collected includes the medical personnel involved, the stage of error, and a brief description of the incident. The reports are analyzed based on Failure Mode and Effect Analysis (FMEA) to demonstrate all possible failures, and the Risk Priority Number (RPN) is calculated to set a priority scale. Furthermore, Bow Tie Analysis (BTA) is conducted to explore preventive and corrective actions of the leading root cause of the highest-priority ones. Results: This study showed that most medication errors occurred at the prescribing stage (39.1%). This outcome emphasized the top priority root cause with the highest RPN value (810). Across all stages, it is known that contraindicated-drug-disease interaction was the most frequently reported error category (24.4%). The data on medication error obtained display that errors are dominated by the no harm level (36.6%), while the cases of severe level were 5 out of 41 incidents (12.2%). Conclusion: The main reasons for medication errors in the prescribing stage were prescription writing errors and patient identification failures. Good patient safety practices are needed to prevent and reduce occurrences, especially the organization that plays an active role in improving safety culture and awareness. Keywords: Medication Error, Patient Safety, Risk Assessment, Tangerang City.