“…The interviewee in the research was the head of medical service, the head of pharmaceutical installation, the staff of pharmaceutical installation, and the staff from the other unit related to the patients. The number of research participant was 30 people (Jacqueminet, 2017). Fishbone analysis was used in FGD based on 5M factors (man, method, machine, material, management) to know the issue cause, then the main factor of each bone was looked for using -5 why‖ method and pursed into 3 main issue causes.…”