Background

Hospital is a health service place that provides emergency, inpatient and

outpatient services. Inpatient department is a department that provides sustainable
services to patients who are being treated in a hospital. Inpatient services are
collaborative services involving professional caregivers, one of which is a nurse.
Nurses in providing services to patients refer to procedures that have been
established by the hospital by considering patient safety principles. One of the
nurse roles is to give medicine for the patient according to advice of the doctor in
charge. In administering drugs to patients, the nurse ensures that the given drugs
are in accordance with the patient's identity, patient dosage, route of
administration and type of medication. The inpatient department has seven correct
procedures in administering drugs, these procedures consist of correct patient,
correct drug, correct dose, correct route of administration, correct time, correct
documentation and correct information (1). Therefore, nurses must apply the
seven correct procedures in administering drugs so that there are no errors in drug
administration.
Errors in administering drugs or medication errors often occur in inpatient patients
which result in disadvantage for patients and endanger patient safety because
nurses did not implement drug administration procedures properly (Budihardjo,
2017). Medication errors have an impact on patients and it is about 3.7% which
causes disability in the patient and due to negligent cases (Pham et al., 2011).
Ehsani et al, (2013) explained that medication errors can increase the length of
stay by two days and increase the cost of around 2000-2500 dollars for each
patient. In the United States there is one death every day and an injury to 1.3
million people each year due to medication errors (5). Meanwhile, in Australia,
9% of medication errors occurred during the drug administration phase (6)

The most often occurred Medication error is the administration phase /

administration of drugs carried out by nurses. Based on research from the UK
National Patient Safety Board, 50% of the various types of medication errors are
medication administration errors, 18% for the dispensing phase, and 16% for the
prescribing phase. In Indonesia, patient safety is an important issue and in 2000
conducted the first case study in 15 hospitals using 4500 medical records. The
results showed that the unexpected incidence rate (it is called KTD in Bahasa)
varied widely, namely 8.0% -98.2% for diagnosis errors and 4.1% -91.6% for
treatment errors (7). Medication errors in Indonesia around 3-6.9% occur in
patients who are hospitalized, around 0.03-16.9% are due to errors in drug
requests, and about 11% are related to errors when administering drugs to patients
(Lolok & Fudholi, 2014).

The results of a preliminary study conducted at X Hospital by searching the

documents from January to June 2020 found 2 (two) incidents of errors in
administering drugs to patients in the inpatient department. Incidents of drug
administration errors can lead to decreased quality of service and affect patient
safety. Based on these data, the aim of this study was to identify the inhibiting
factors for the implementation of the seven correct procedures for drug
administration at X Hospital as well as to find alternative solutions for the found
obstacles.

Method
This research used quantitative research with analytic observational research
design. Data collection was carried out using observation and survey techniques.
The method of observation aimed to see the level of compliance of officers in
carrying out drug administration procedures with the right 7 principles. The
survey was conducted by using a structured interview method and a questionnaire.
The questionnaire method was carried out to see a description of the knowledge,
attitudes, willingness of nurses in carrying out the drug administration procedure
with the 7 right principles. Interviews were conducted to gather information
related to the application of drug administration procedures with the 7 right
principles.

Researchers conducted observations for 3 days in the morning, afternoon and

evening shifts with researchers as observers based on certain considerations made
by the researchers themselves, namely researchers working at the research site and
knowing the characteristics of the respondents or informants. The research
instrument used an observation sheet in the form of a checklist containing 13
statements with yes and no answers. The observation sheet was used to see and
measure the implementation of the correct principle of drug administration based
on criteria developed from the 7 right principles of drug administration according
to Sri Lestari 2016. The used observation sheet refers to the correct procedure for
administration of drugs, including correct patient, correct drug, correct time,
correct how to administer, correct dosage, correct information and correct
documentation, so that researchers do not test the validity and reliability.
Researchers distributed questionnaires related to the knowledge, behavior,
attitudes and willingness of nurses in the application of drug administration with
the 7 right principles. This research used total sampling, which means that the
selected sample in the study of all members of the population. Sampling in this
reasearch was obtained from the total number of nurses in the Inpatient
Department of X Hospital totaling 20 nurses. The distributed questionnaire
consists of 5 parts, the first was regarding the demographic data of the
respondents, the second was measuring the knowledge of the application of drug
administration with 25 questions using multiple choice answers, the third was
measuring respondents behavior in the application of drug administration with 12
statements, the fourth measures the attitude of nurses in the application. The
administration of drugs with 11 statements and the fifth measure the willingness
of nurses in the application of drug administration with 2. In addition to the
questionnaire with closed questions, the researcher also gave 2 open questions
regarding the factors that hinder the implementation of drug administration with
the 7 right principle. The questionnaire scores on behavior, attitude and
willingness use a Likert scale. The Likert scale has a value level from very
positive to very negative which can be in the form of words including: Strongly
Agree (SS), Agree (S), Disagree (KS), Disagree (TS), Strongly Disagree (STS).

Researchers conducted interviews with nurses in inpatient departments by using

nonprobability sampling techniques by purposive sampling, sampling based on
certain considerations made by the researcher, based on previously known
population characteristics or characteristics (Dharma, 2011). Researchers
conducted interviews with 5 nurses in inpatient departments, based on the
working period, that were divided in to periods of 1-3 months, 1-2 years and
more than 2 years. Unstructured interviews were conducted to obtain information
about inhibiting factors for the application of drug administration with the right 7
principles.

The results of observations, questionnaires and interviews were collected

and grouped for processing. Data from observations and questionnaires are
presented in tabular form and then described for easy analysis, while data from in-
depth interviews are presented in narrative form and then described. Researchers
conducted a search for the root cause of the inhibiting factors for the application
of the drug administration procedure with 7 right procedures from the results of
data analysis obtained. The method of finding the root of the problem uses a
fishbone diagram through a brainstorming session with the director, the head of
the inpatient department and the head of the pharmacy department. The results of
the brainstorming then become material for selecting priority problems using the
USG method. The identification of alternative solutions and selection of solutions
is carried out through discussions with hospital management.

Result
An overview of the correct application of the procedure for administration of
drugs
The characteristics of the respondents in this study were age, gender and
education level. The distribution of respondent characteristics can be seen in
Table 15

Table 15. Characteristics of respondents

No Respondent characteristics frequency (n) Presentage (%)

1. Gender
Female 20 100%
Male 0 0%
2. Age
21-25 13 65%
25-30 5 25%
31-35 2 10%
3. Last education
Ners 5 25%
D3 15 75%
Total 20 100%
Table 15 shows that out of 20 nurses (100%) are female. Based on age, the
highest percentage was in the 21-25 year age group, namely 13 people (65%),
while the lowest percentage was in the 31-35 year age group, namely 2 people.
Based on the level of education, it shows that the contribution of nurse education
with the highest percentage is Diploma III, which is 15 people (75%). While the
lowest percentage was educated by Ners, namely 5 people (25%)
The application of the drug administration procedure with the 7 principles
correctly shows very good results, but there are 4 principles that have not been
maximally applied, namely correct patient, correct method of administration,
correct information and correct documents. The results of the patient's correct
observation showed that the nurse was lacking in the patient's correct procedures.
In implementation there are still nurses who do not match the patient's name with
the patient's identity bracelet. If the nurse does not identify the patient correctly, it
will result in an error in administering medication. The correct results of the
method of administration with indicators to see drug expiration indicate the
application of drug administration procedures with good criteria. However, in
implementation there are still nurses who do not see the expiration date of the
drug. This is due to the fact that nurses are less careful and result in the drug
administration process taking longer. The correct way of administering drugs by
looking at the expiration date must be considered by the nurse, given the harmful
effects of expired drugs. The impact caused is that it can increase the incidence of
drug administration errors.
Based on the results of the observation of the correct principle of information with
the indicator nurse writing down the information provided in the form of
integrated educational notes in medical records shows a good category. Recording
information in an integrated educational record form is one way of
communicating between officers. Nurses record information related to how to
take medicine and education in administering medicine, but there are still nurses
who have not applied it. This is due to the long process which will increase the
workload. Complete recorded information will reduce the incidence of drug
administration errors.
Based on the results of correct observation, the documentation shows unfavorable
results. The activities of nurses in documenting drug administration according to
standards that must be carried out, namely writing the full name of the patient, the
time of administration, the required drug dose, the frequency of administration of
the drug, the patient's response after drug administration and if there is a drug
effect, the time, date and name of the officer give and who write prescriptions in
medical records. Nurses often forget about documenting activities and switch to
other activities or jobs, due to high workloads, lack of supervision of compliance
with medical records and lack of understanding of procedures. This has an impact
on hospital services, such as the absence of evidence that nurses take medication,
increasing the risk of repeated drug administration and the risk of drug
administration errors.
Knowledge of nurses about administering drugs with the principle of 7 rightly has
good knowledge as many as 10 people (50%) with a mean value of 73, nurses
have very good knowledge as many as 9 people (45%) a mean score of 90 and
nurses have good enough knowledge as many as 1 person (5 %) with a mean
value of 60. Based on the results of the questionnaire, it shows that the majority of
nurses have good knowledge (50%), as many as 10 people. Nurses' knowledge of
the drug administration procedure with 7 principles is correct but needs to be
improved Good knowledge can improve the implementation of drug
administration procedures so as to prevent drug administration errors.
The results of the questionnaire on the behavior of nurses in the drug
administration procedure showed that there were 4 nurses' behaviors which were
quite good. The nurse's behavior with a fairly good category is found in the
correct patient, correct method of administration, correct information and correct
documentation. This is in accordance with the results of observations made by
researchers. If the nurse's behavior is not changed it will hamper the application of
drug administration procedures and the impact can increase the incidence of drug
administration errors.
The results of attitudes that show a good category are found in nurses who feel
that it is necessary to provide input to doctors for correct application of
indications (65%), nurses feel that application of 7 is correct to increase workload
(65%), nurses feel that applying 7 is correct makes more discipline in giving
medication (75%), nurses felt that the standard 7 is correct makes them more
consistent and disciplined (75%), nurses feel that they have to make sure the
medicine has been taken (65%), nurses feel that Medication errors can occur if
principle 7 is not implemented (65%), and nurses felt that applying 7 was correct
made it easier to administer the drug better (80%). The attitude result shows that
the category is quite good, namely the nurse feels that they are forced to do the
right 7 principles in administering the drug (60%).
The attitude of the nurses in implementing the drug administration procedure
showed the majority of the results were in good categories. Attitudes of nurses
towards implementing drug administration procedures need to be improved. The
result of the attitude that shows the category is quite good, namely the nurse feels
that they are forced to do the right 7 principles in administering the drug. This is
because the drug administration procedure takes a long time to increase the
workload. The nurse's attitude can hinder the application of drug administration
procedures
To determine the relationship between attitudes towards behavior in applying
SOPof drug administration, the chi square test was used because of the nominal
categorical attitude and the ordinal categorical behavior. The sig value of the chi
square test between attitudes towards behavior does not appear because the
attitude variable is constant. To determine the relationship between knowledge
and behavior in applying SOPof drug administration, the chi square test was used
because knowledge was nominal categorical and behavior categorical ordinal.
Following are the results of the chi square test:

Table 2. Chi-Square Tests

Because the value of expected count less than 5 is 75%> 20%, it does not meet the
chi square test, so it uses the alternative test, namely Fisher's test. The sig value in
Fisher's test is 0.266> 0.05 so it is not significant. This means that there is no
relationship between knowledge and behavior in implementing SOPof drug
administration.
Based on the results of the open-ended questionnaire, there were several inhibiting
factors in the application of the drug administration procedure, namely human
resource (HR) factors, patient factors, method factors and environmental factors.
The human resource factor that becomes an obstacle in the application of drug
administration is that the officers are less careful in administering drugs due to the
long time needed in the drug administration process so that it will increase the
workload of the nurses. The factor of lack of nurses will affect the implementation
of the procedure for administering drugs to patients, nurses tend to rush in
carrying out these procedures and can cause errors in drug administration. The
drug administration procedure is not yet available in the inpatient department,
which causes nurses to not comply with the procedure, this can hamper the
implementation of services to patients. Disobedience of officers can be caused by
lack of maximum supervision performed by the head of the inpatient department.
These factors can have an impact if the procedure for drug administration with the
principle of 7 is not properly implemented.
The results of the interview showed that of the five informants, there were 2
informants who said that administering drugs with the principle of 7 rightly took a
long time to increase the workload of the officers, 3 informants said that the
procedure had never been explained and had never seen the procedure, 3
informants said that they were not thorough in providing medication to the patient
and does not correctly identify the patient.

Identify the problem root

From the results of observations, questionnaires and interviews with nurses, it was
found that several factors inhibited the implementation of the seven correct
procedures for administering drugs in inpatient departments. With the fishbone
diagram analysis method, several root causes can be identified (Figure 1). The
problem of inhibiting factors for the implementation of the correct procedure for
administering the drug to be fish heads in the fishbone diagram. The fish bones in
the fishbone diagram are the root cause of the problem. The factors that hinder the
application of the correct drug administration procedure are man factors, machine
factors, method factors and environmental factors.
From the man factor, it shows that there are limited personnel that can affect the
drug administration process, officers tend to be in a hurry to prepare and
administer drugs. Lack of compliance with officers can also hinder the delivery of
drugs to patients. Lack of discipline and accuracy from officers and lack of
communication between officers can hinder the administration of drugs correctly.
Method factors that hinder the application of drug administration procedures,
namely the absence of standard operating procedures (SPO) for drug
administration with the principle of 7 right, with no procedure or flow will cause
officers to be more careless in providing services to patients. Procedures are
needed by organizations to build systems and uniformity in providing services. If
there is no drug administration procedure in the inpatient department, it will
hamper the implementation of drug administration and reduce the compliance of
officers. The machine factor shows that officers need a long time and there is no
supervision system in drug administration procedures. Environmental factors
show that patients are not adherent to taking medication, the nurse station is not
wide enough and there are interruptions in the drug preparation process. These
factors can hinder the application of the drug administration procedure with the
right 7 principles.

Root cause problems with fishbone diagrams

MAN It took a long

Lack
time
of communication
ENVIRONMENT
METHODE The patient is not obedient in
between care givers taking medication

Limited energy
There is still no SOPfor proper
Lack of compliance drug administration

Lack of discipline and thoroughness

Less spacious nurse station

The absence of a
supervisory system in drug Interruptions to the drug
administration procedures preparation process

MACHINE
Furthermore, the priority root problem selection was carried out using the USG
method involving the Director, Inpatient and Pharmacy Department.

Table 2 Priority root problems with the ultrasound method

Root problems U S G Total Ranking
The absence of SOPfor drug administration 5 5 5 15 I
according to the reference
Lack of compliance of officers in administering 4 5 4 13 II
drugs to patients

Based on the USG method, it shows that the root cause of the problem chosen
with the highest score is the absence of SOPin administering drugs correctly
according to the latest standards. SOPis a tool or instrument used by officers in
carrying out their duties in providing services to patients. SOPfor drug
administration with procedure 7 really focuses on preventing drug administration
errors. Based on the results of the study (9) preventing the occurrence of drug
administration errors by making guides, flowcharts, and making changes to
procedures and methods according to hospital conditions.

Discussion
There is no SOPaccording to principle 7 is correct
One of the root causes is the perception of nurses regarding drug administration
procedures that have not been reviewed, so they still use standards that are not in
accordance with the latest references. Existing procedures do not describe the
steps in properly administering the drug. Therefore, it is necessary to review and
revise the procedure for drug administration by finding the latest reference
sources. The review and revision was carried out together with the hospital
pharmacy department with discussion methods and procedures made according to
the rules of procedure for making SOPat X Hospital.
Standard Operating Procedure (SOP) is a set of instructions / standardized steps to
complete certain routine work processes, with the aim that various routine work
processes are carried out efficiently, effectively, consistently / uniformly and
safely in order to improve service quality through meeting standards applies.
SOPis useful for documenting activity steps and ensuring hospital staff understand
a process in carrying out their work (10).
SOPcompleteness and service flow is very influential to support the operational
activities of the organization or company to run smoothly. Incomplete SOPand the
absence of service flow will have an impact on the work system of the work unit
concerned. The SOPalso has to set the sequence of steps (or work
implementation), where the work is done, how to do it, when to do it, where to do
it, and who does it. From the SOPwhich is applied at X Hospital related to drug
administration, it is divided into several categories according to the way the drug
is administered, including SOPfor administering oral, intravenous and
intramuscular drugs as well as SOPfor patient identification before giving the
drug, but there is no specific SOPregarding the process of administering drugs
with Principle 7 is correct. This can be seen from the results of interviews,
questionnaires with open-ended questions and direct observation when officers
give drugs to patients in the inpatient department.
Guidelines or SOPis true that drug administration that is determined and
applicable in the hospital is one of the tools to evaluate and prevent medication
errors to patients so that the administration of drugs is safe and patient safety is
maintained (11). SOPas a guide for nurses in the action of administering drugs in
accordance with the principle so that errors in administering drugs can be
prevented, patient satisfaction and quality of service in the hospital can be
increased (Hastuti, 2018). SOPfor drug administration with the principle of 7 right
must be carried out by all officers, if in practice the officer does not apply the
steps that have been determined, it will cause an error in the administration of the
drug Drug administration errors have a negative impact on patients, staff and
hospitals. The impact on the patient can cause death and the impact on the staff
and the hospital, namely lawsuits from the family. Therefore, the hospital is
obliged to determine the procedure for drug administration with the principle of 7
right.
After revising the SOPfor drug administration with the principle of 7, it is
necessary to do socialization to inpatient officers. Socialization is the process of
studying and instilling values, norms, roles and behavior patterns from one
generation to another in a group or society in order to participate in social life.
Socialization is very important for all individuals because it can increase
compliance in implementing SPOs (Sari, Suprapti & Solechan, 2014).
Socialization can be done in oral form and provision of SOP documents
containing a description and flowchart. The existence of began will make it easier
for officers to understand SPOs and maintain consistency in carrying out work
procedures. This is in accordance with research (12) that there is a significant
relationship between socialization and the implementation of drug administration.
6 Correct. X Hospital has a reference about the rules for socialization. To increase
the compliance of officers in implementing SPO, the socialization needs to be
repeated to officers with a good method so that the meaning and meaning of what
is being socialized can be understood. Socialization can be done during hand over
shifts in the morning, afternoon and evening and during weekly and monthly
meetings.

Lack of compliance by nurses in administering drugs to patients

The inhibiting factor for the application of drug administration procedures is the
lack of compliance by nurses in administering drugs to patients. Nurses'
compliance in carrying out SOPs of drug administration with the 7 principle is
correct depending on the behavior of the nurse itself, this is in accordance with the
opinion (Mustiana, 2014) that compliance is part of the behavior of the individual
concerned to obey or obey something. According to Ulum and Wulandari, 2013
nurse compliance is a nurse's behavior as a professional towards a
recommendation, procedure, or regulation that must be done or obeyed. The
prescribed drug administration procedure can minimize the occurrence of side
effects or errors in administering drugs by increasing compliance with the
application of the correct principles of drug administration. Nurse compliance can
be improved by conducting education and training (diklat) and supervision.
X Hospital annually creates education and training programs, training which is
held based on the proposed department / work unit. The head of the inpatient
department needs to propose training in administering medicine with the right 7
principle, so that nurses are obedient in carrying out the procedure with the aim
that there are no errors in administering drugs. According to (Permenkes, 2017)
continuous education and training are also needed to improve and maintain staff
competence and support an interdisciplinary approach in patient care. The skills
possessed by nurses will affect the incidence of medication errors as in the results
of Budihardjo's research (2017), namely that there is a relationship with skills
with medication errors. The training is conducted using an internal workshop
method by providing pre-test and post-test, presenting material and videos and
direct practice with colleagues. This is in line with research conducted by Sofiani
& Sundari (2016) that training with the lecture method accompanied by
discussion, simulation and practice can increase knowledge. The training material
that is given properly will certainly lead to persistence from the training
participants, according to researchers (Sofiani and Sundari, 2016) the material
provider or trainer makes the material neatly and from the latest and applicable
sources so that participants can easily understand it and then put it into the
process. daily care.
Nurses' compliance in implementing drug administration procedures plays a very
important role, if the nurse is negligent it will result in errors in drug delivery. In
the results of interviews with officers, it was found that the less optimal
application of drug administration procedures was due to the officers' non-
compliance. To increase the compliance of officers, it is necessary to carry out a
method of supervision (supervision) carried out by the head of the room.
According to (Abdurrahman, 2019) compliance is influenced not only by
individual factors, but from factors of a supportive work environment such as the
supervision of the head of the room which is one of the activities in the directive
function in the management function.
Supervision is a monitoring and coaching activity carried out continuously by
supervisors covering nursing service problems, workforce problems, and
equipment so that patients receive quality service (Nursalam, 2014). The
successful application of the seven correct principles of drug administration is
very influential from the role of the head of the room who carries out supervision.

Conclusion
The inhibiting factors for the application of the drug administration procedure in
the X Hospital inpatient were the incomplete SOPand the non-compliance of
nurses in administering drugs to patients. This study also shows that knowledge is
not related to nurses' behavior in applying the seven correct drug administration
procedures. Based on the results of the best alternative solutions to overcome
these problems are revising the SOP, disseminating it to all staff, holding training
in the form of an internal drug administration workshop with the 7 right principles
and supervising the implementation of the procedure for administering drugs with
the 7 right principles.