Peningkatan mutu dan keselmatan pasien merupakan dua hal yang tidak bisa dipisaahkan dan harus berkesinambungan. Upaya peningkatan mutu dan keselamatan pasien di Instalasi Farmasi Rumah Sakit Pusat Otak Nasional Prof. DR. dr. Mahar Mardjono digambarkan melalui capaian indicator pelayanan menurut Standar Pelayanan Minimal Rumah Sakit yang belum mencapai standar. Penelitian ini dilakukan untuk menganalisis waktu tunggu pelayanan obat jadi pasien JKN dan aktivitas risiko terjadinaya medication error dengan prinsip lean thinking dan swiss cheese model. Jenis penelitian ini adalah operational research dengan pendekatan kualitatif dan kuantitatif. Data kualitatif diperoleh melalui proses observasi dan telaah dokumen, sedangkan kuantitatif berdasarkan data waktu tunggu dari electronic health record dan waktu tunggu hasil observasi. Hasil penelitian menunjukan waktu tunggu adalah 1 jam 3 menit 11 detik, dengan waktu tunggu terlama adalah pada proses penerimaan resep (30 menit 42 detik). Kegiatan VA (79%) yaitu 13 menit 13 detik. Aktivitas NVA (21%) dengan waktu 49 menit 21 detik. Waste terbanyak adalah pada kegiatan waiting dengan presentasi waktu 92% dari waktu NVA. Bottleneck pada penelitian ini diambil dari proses waktu tunggu terlama dan hasil analisis swiss chesse model pada tahapan pengkajian dan pemeriksaan sediaan obat.Usulan perbaikan berdasarkan hasil analisis proses pengkajian dan pelayanan resep obat jadi ini adalah perlu adanya penyusunan regulasi pengkajian dan pelayanan obat sesuai standar pelayanan kefarmasian, telaah profil indicator waktu tunggu obat jadi sesuai SPM rumah sakit, perlu adanya analisis beban kerja, dan monitoring supervise kajian pelayanan resep obat. Usulan perbaikan digambarkan dalam future state map dengan mereduksi aktivitas NVA yang dapat secara langsung dihapuskan tanpa dilakukan intervensi. Kata kunci: lean thinking, , medication error, swiss chesse model waktu tunggu pelayanan

Quality improvement and patient safety are two things that cannot separated and must be continuous. Effort to improve quality and patient safety at Outpatient Pharmacy Pusat Otak Nasional Prof. DR.dr. Mahar Mardjono Hospital is described through the achievement of service indicators according to the hospital minimum service standards thet have not resched the standard. This study was conducted to analyze the waiting time for JKN patient medication services and risk activities of medication errors using principles of lean thinking and the swiss cheese model. This type of research is operational research with qualitative and quantitative approaches. Qualitative data is obtained through the process of observation and document review, while quantitative data is based on waiting time data from electronic health records and waiting time for observations. The result showed that the waiting time was 1 hour 3 minutes 11 seconds, with the longest waiting time was in the process of receiving the recipe (30 minutes 42 seconds). Value_added activity (79%) was 13 minutes 13 seconds, non value added activity (21%) for 49 minutes 21 second. Most of waste is in waiting activities with a presentation time of 92% of the time for non value added. The bottleneck in this study was taken from the longest waiting time process and the result of the swiss cheese model analysis at the assessment and examination stage of drug preparations. Reviewing the waiting time indicator profile for the finished medicine according to the SPM of the hospital. There is a need for workload analysis, and monitoring of the review of prescription services. Proposed improvements are described in a future state map by reducing non value added activity which can be directly eliminated without intervention. Key words: lean thinking, medication error, swiss chesse model, medication error, service waiting time