133 
 

PREVENTING MEDICATION ERROR BASED ON KNOWLEDGE MANAGEMENT 

AGAINST ADVERSE EVENT  

 

Apriyani Puji Hastuti*, Nursalam**, Mira Triharini** 

*Nursing Study Program- Poltekkes RS dr Soepraoen Malang 

**Nursing Faculty - Universitas Airlangga Surabaya 

Email: ns.apriyani@gmail.com 
 

ABSTRACT 

Introductions: Medication error is one of many types of errors that could decrease the quality and safety of healthcare. 

Increasing number of adverse events (AE) reflects the number of medication errors. This study aimed to develop a model of 

medication error prevention based on knowledge management. This model is expected to improve knowledge and skill of 

nurses to prevent medication error which is characterized by the decrease of adverse events (AE). Methods: This study 

consisted of two stages. The first stage of research was an explanative survey using cross-sectional approach involving 15 

respondents selected by purposive sampling. The second stage was a pre-test experiment involving 29 respondents selected 

with cluster sampling. Partial Leas square (PLS) was used to examine the factors affecting medication error prevention model 

while the Wilcoxon Signed Rank Test was used to test the effect of medication error prevention model against adverse events 

(AE). Results: Individual factors (path coefficient 12:56, t = 4,761) play an important role in nurse behavioral changes about 

medication error prevention based in knowledge management, organizational factor (path coefficient = 0276, t = 2.504) play 

an important role in nurse behavioral changes about medication error prevention based on knowledge management. Work 

characteristic factor (path coefficient = 0309, t = 1.98) play an important role in nurse behavioral changes about medication 

error prevention based on knowledge management. The medication error prevention model based on knowledge management 

was also significantly decreased adverse event (p = 0.000, α <0.05). Discussion: Factors of individuals, organizations and 

work characteristics were important in the development of medication error prevention models based on knowledge 

management. 

Keywords: Medication error, knowledge management, adverse events (AE) 

 

 

INTRODUCTION 

 Medication error is one type of error that 

gets the most attention effort to improve the 

quality and safety of healthcare because it can 

increase the cost of health care in large 

numbers. Some of the most common 

medication errors are misconduct, incorrect 

dosages, and incorrect intervals (FM Hurtsey, 

2007). Nurses and other health professionals 

involved in the Management and Use of Drugs 

(Medication Management and Use/MMU) 

have a responsibility to create an environment 

and working practices that prioritize the patient 

safety. Medication error is deemed to occur if 

drug chart of patients showed any of the 

following: illegible handwriting, medication 

name and dosage error, medication admission, 

and access, discharge medication (Wei, 

Shrestha, Williamson, & Morgan, 2011). 

Efforts should be made to improve safety in 

drug delivery include national efforts, 

education, and training for nurses and system 

changing (Roterman, 2014). 

 Studies related to the causes of 

medication errors have been done and the 

result shows that lack of knowledge 

dissemination, especially 22% of the doctors 

who constitute the cause of error, insufficient 

information about the patient as well as 

laboratory data test and possibly the cause of 

dosing error is 10% does not obey the standard 

operational procedure and forgot 9% as the 

cause of medication errors. Another causes 

related to misreading the prescription, wrong 

interpretation and abbreviations commands of 

prescription, misunderstanding verbal 

commands, confusing the nomenclature of 

labeling and packaging, wrong storage of 

medicine, standard and distribution problem, 

error delivery when purchasing and using drug 

for example chemotherapy drug infusion, 

disruption of tension and work environment; 

unknowledgeable patients (Roterman, 2014).  

 Based on the report of Hospital Safety 

Committee in 2010, incidences of medication 

errors during January-April 2010 reached 

16.67%. Nationally, 36% of medication errors 

occur in the administration phase (Paparella, 

2011). In the period of May until August 2010, 

there was 11.1% incidence of medication 

errors or third ranks incident after incident 

errors in clinical procedure and patient falls. 

The high incidence of medication errors due to 

patient safety needs serious attention from 

health professionals, especially nurses who 

play a role in the administration of drugs 

mailto:ns.apriyani@gmail.com


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134 

 

(medical administration). Medication errors 

can cause serious adverse effect and potentially 

to evoke the fatal risk of the disease 

(Perwitasari, Abror, & Wahyuningsih, 2010). 

 A preliminary study conducted on April 

16, 2016, at RSUI Malang found that the 

number of patients with uncontrollable drug 

reactions and the medication error in January - 

December 2015 were 30 cases with the 

majority of patients are allergic to analgesic, 

antipyretic and antibiotic drugs. Quality 

Improvement of Patient Safety Team of RSUI 

Malang has conducted risk grading including 

medium risk, simple investigation to the 

incident at the longest two weeks and the 

leadership commitment to manage the risk in 

preventing medication error. From the 

observation, it is found that there were still 

errors in drug injection and delivery 

medication schedule. While on the 

documentation aspect, the nurse only wrote 

down the activity of medication that has been 

done without a report or wrote the patient's 

response to the medication that has been given. 

 Medications are classified based on 

potential risk for medication errors/adverse 

drug events: high risk, moderate risk and low 

risk (Swinkey & Manthey, 2001; Zafar, 2007). 

Adverse event occurs due to the negligence of 

the nurse and medication errors. This fault 

happens because of high workload and a high 

number of inpatient. Knowledge management 

in the institution to organize knowledge and 

facilitate employee to access information so 

that employees are informed and can apply it 

and affect employee performance. Most 

knowledge can be obtained from some factors 

that include education, experience themselves 

or other people, the mass media and the 

environment. Domain knowledge is very 

important for the formation of a person's 

behavior (W. Maalej, 2013). To prevent 

adverse event cause of medication error, The 

supportive strategies for improving perception 

for the use of IT-based systems would add to 

system construction, and positive error 

management climate would be more easily 

promoted (Kim, 2012) 

 Knowledge management approach will 

be used in the prevention of medication errors 

(Gasik, 2011). Knowledge management 

according to Gasik (2011) is a development of 

the concept of knowledge management by 

Nonaka and Takeuchi (1995). Knowledge 

management has 7 stage, there are 

identification; knowledge acquisition, 

knowledge creation, knowledge application, 

knowledge transfer, knowledge sharing, 

knowledge documentation. The advantages of 

this model are on the data processed through 

collecting, classifying and grouping, so that it 

changes the shape and nature of their intended 

use, interpret the data, data storage, data 

delivery to the user, and its usefulness in 

supporting the interests of the organization. 

This model is based on the traditional model of 

quality and excellence so that there is a very 

strong relationship between knowledge 

management processes and organization with 

the expected results. The role of knowledge 

management as a whole is positioned as a tool 

that helps organizations to achieve the goal. 

Knowledge management approach is the 

concept of managing knowledge that has been 

established to be applied to practice by the 

knowledge that has been gained and reflected 

in the performance of a nurse so that 

unexpected events related to the administration 

of drugs can be minimized. 

 

METHODS 

 The first stage was explanative survey 

using cross-sectional and second stage was 

pre-experiment, the purpose was to prepare a 

model of medication error prevention-based on 

knowledge management model including to 

raise strategic issues of nurses. Respondents in 

the first stage are 31 nurses in the ICU, Firdaus 

and Mina rooms which selected by purposive 

sampling. The purpose of the second stage was 

a trial of medication error prevention-based 

model of knowledge management against 

unexpected events. Data were collected using 

questionnaires, observation and analyzed by 

using Partial Least Square (PLS). PLS results 

and strategic issues then lifted into the Focus 

Group Discussion (FGD) with the aim to 

develop a medication error prevention module-

based knowledge management. Participants of  

FGD were 15 respondents consists of team 

Patient Safety, Nurse Unit Manager (NUM), 

the nursing committee selected by purposive 

sampling. Nurses implemented a module that 

resulted by FGD in the second stage of 

research. Respondents of the second stage are 

29 in room Safa - Marwah, Mumtazah and 

Arofah which collected by using cluster 

sampling. Respondents of the second phase 

were observed in implementing the module of 



Preventing Medication Error Based on Knowledge Management (Apriyani Puji H. et.al) 

135 

 

medication error prevention - based on knowledge management to the adverse event 

and the data were analyzed using the Wilcoxon 

Signed Rank Test 
 

RESULTS  

The results of the first stage 

described the causes of medication error 

(individual factors, organizational 

factors, job characteristic) and prevention 

of medication error based on knowledge 

management (assessment, planning, 

implementation, evaluation). The 

distribution of respondents’ answers can be 

seen in table 1 and table 2. 

Table 1 shows the cause of 

medication error including individual 

factors, organizational factors, and 

respondent’s work characteristic.  

 

Table 1. Distribution Causes of Medication Error 

No Indicator 
Good 

f (%) 

Moderate 

f (%) 

Low 

f (%) 

Total 

f (%) 

Individual Factors 

1 Knowledge 0 24 (77%) 7 (23%) 31 (100%) 

2 Ability and skill 0 31 (100%) 0 31 (100%) 

3 Psychological 0 30 (97%) 1 (3%) 31 (100%) 

Organizational Factors 

1 Organizational 

Comitment 
1 (3) 30 (97) 0 31 100%) 

2 Structur & 

Organizational culture 
0 27 (87%) 4 (13%) 31(100%) 

Respondent’s Work Characteristics 

1 Objective performance 0 31 (100%) 0 31 (100%) 

2 Feedback 7 (23%) 24 (77%) 0 31 (100%) 

 

Tabel 2. Prevention of medication error based on knowledge management 

Indicator 

Category 

Total Good  

f (%) 

Moderate  

f (%) 

Low  

f (%) 

Assessment     

Knowledge identification - 23 (74%) 8 (26%) 31 (100%) 

Knowledge application 1 (3%) 26 (84%) 4 (13%) 31 (100%) 

Knowledge Sharing and Transfer 2 (6%) 17 (55%) 12 (39%) 31 (100%) 

Knowledge repository 0 27 (87%) 4 (13%) 31 (100%) 

Intervention     

Knowledge identification - 25 (81%) 6 (19%) 31 (100%) 

Knowledge application - 29 (94%) 2 (6%) 31 (100%) 

Knowledge Sharing and Transfer 5 (16%) 21 (68%) 5 (16%) 31 (100%) 

Knowledge repository 1 (3%) 22 (71%) 8 (26%) 31 (100%) 

Implementation     

Knowledge identification - 30 (97%) 1 (3%) 31 (100%) 

Knowledge application - 31 (100%) - 31 (100%) 

Knowledge Sharing and Transfer 2 (6%) 26 (84%) 3 (10%) 31 (100%) 

Knowledge repository 2 (6%) 21 (68%) 8 (26%) 31 (100%) 

Evaluation     

Knowledge identification 2 (6%) 21 (68%) 8 (26%) 31 (100%) 

Knowledge application - 25 (81%) 6 (19%) 31 (100%) 

Knowledge Sharing and Transfer 2 (6%) 20 (65%) 9 (29%) 31 (100%) 

Knowledge repository 4 (13%) 22 (71%) 5 (16%) 31 (100%) 

 

 



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For individual factors, mostly the 

knowledge of respondents in preventing 

medication error is in the moderate category 

(77%).  All respondents (100%) have the 

ability and skill in the moderate category, and 

most respondents have psychological factor in 

the moderate category (97%) for 

organizational factors, organizational 

commitment in preventing medication error 

mostly in sufficient category (97%) and 

organizational structure and culture mostly in 

enough category (87%). For respondent’s work 

characteristics, the objective performance of all 

respondents in sufficient category are (100%), 

and feedback from the leadership in the 

sufficient category are 24 people (77%). 

As seen in Table 2, in the assessment phase, 

23 people (74%) has moderate knowledge 

identification, 26 people (84%) has moderate 

knowledge application, 17 people (55%) has 

moderate knowledge sharing, and transfer and 

27 people (87%) has moderate knowledge 

repository. In the planning stage, the majority 

of respondents has moderate knowledge 

identification (25 people), moderate 

knowledge application (29 people), moderate 

knowledge sharing and transfer (21 people) 

and moderate knowledge repository (22 

people). In the implementation phase the 

majority of respondents to the knowledge 

identification quite as many as 30 people 

(97%), knowledge application as many as 31 

people (100%), knowledge sharing and transfer 

as many as 26 people (84%) and knowledge 

repository as many as 21 people (68%). In the 

evaluation phase the majority of respondents to 

the knowledge identification as many as 21 

people (68%), knowledge application as many 

as 25 people (81%), knowledge sharing and 

transfer as many as 20 people (65%) and 

knowledge repository as many as 22 people 

(71%). Observation result of 31 nurses from 

three rooms ICU, Mina, and VIP Eden who 

implement drug administration to patients 

through a variety of routes showed that adverse 

event is still happening as much as 1.5% 

 

Model Development of Prevention Medication 

Error  Based on Knowledge Management 

The results of the evaluation outer 

convergent value model validity can be seen in 

the following figures and tables. Based on 

picture 1, it can be seen that all the indicators 

declared invalid where the value of outer 

loading by the expected criteria is above 0.5. 

This shows that the whole indicator in the 

structural are valid.  

Results Composite reliability to test 

the value of reliability indicators in this study 

can be seen in Table 3.

 

 
 

Picture 1 Outer loading Value on Prevention medication error model based on Knowledge 

Management 

 



Preventing Medication Error Based on Knowledge Management (Apriyani Puji H. et.al) 

137 

 

Table 3. Results of Convergent Validity of the Prevention medication error model based on 

Knowledge Management 

No Variable 
Concronbach 

Alpha 
Composite Reliability Note 

1 Individual factor 0.733 0.834 Valid 

2 Organizational factor 0.769 0.867 Valid 

3 Work characteristic 0.668 0.858 Valid 

4 Prevention medication error 

based on knowledge 

management 

0.777 0.857 Valid 

 

Table 4. Statistical result of several variables that potentially prevent medication errors 

No Variable Result Note 

1 Individual factor  Path coefficient = 0.560 

Standard deviation = 0,120 

T statistic = 4,671 

Significant 

2 Organizational factor Path coefficient = 0,276 

Standard deviation = 0,110 

T statistic = 2,504 

Significant 

3 Work characteristic factor  Path coefficient = 0,309 

Standard deviation = 0,155 

T statistic = 1,988 

Significant 

4 Prevention medication error 

based on knowledge 

management 

Path Coefficient = -0,486 

Standard deviation = 0,063 

T Statistic = 7,704 

Significant 

 

The value of each variable composite 

reliability study showed a value of > 0.7. 

Cronbach alpha value of each variable also 

showed a value of > 0.6. It can be concluded 

that each variable has met reliability test. 

These results indicate that there is a 

significant relationship between the variables 

individual, organization, and work towards the 

prevention of medication errors characteristic-

based on knowledge management. There is a 

significant relationship between medication 

error prevention - based on knowledge 

management against the adverse event. The 

negative sign of the coefficient indicates the 

inversely proportional relationship means that 

the higher prevention medication error factor-

based on knowledge management will 

decrease the incidence rate of an adverse event. 

 

Recommendation of Focus Group Discussion 

(FGD) for module development in the 

prevention of medication error based on 

knowledge management against  adverse event 

 

1. Socialize about the adverse event and near 
missed to the nurses and allowed nurses to 

report to the Nurse Unit Manager and 

documented in patient safety report. 

2. Patient safety report should regularly be 
reported to the patient safety team every 

week so that the risks can be found and 

prevention can be done immediately. 

3. Socialize related to principles of correct 
drug administration and completeness of 

drug delivery instrument documentation 

sheet 

4. Change the time of drug administration if 
the set time is still not applicable; give the 

autonomy to the each room related the drug 

administration so that the effectiveness of 

the drug is also noteworthy. Time of drug 

administration implemented 10.00-18.00- 

02:00 hours 

5. Documenting drug administration should be 
relevant to what is done by each nurse. 

6. There is a reward for the room which 
carries out regular reporting of patient 

safety incidents and for the room with the 

most minimally incident related patient 

safety.  

7. Sustainability and innovation in the 
prevention of medication errors should be 



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considered to be applied continuously and 

improve patient safety. 

 

Phase 2 

The trial of the model conducted from 

May 8, 2016. The pre-test conducted in 10-day 

by observation of nurses behavior in 

preventing medication errors and unexpected 

events. Firstly, the module is given to nurses in 

Arofah Safa and Marwah and researcher 

explain about the module. Researcher 

accompanied the nurse in administering the 

drug for two weeks in the morning shift. After 

two weeks nurses perform independently until 

ten days and researcher observe it as a post-

test. 

The results of pre-test and post-test of 

implementation of the application of 

medication error prevention module-based on 

knowledge management can be seen in Table 

5.

 

Table 5. Results of Implementation of Medication Error Prevention-Based on Knowledge 

Management against adverse event 

 

Prevention medication 

error based on knowledge 

management 

Pre  Post 

 Good enough less Good Enough less 

Assessment     

Knowledge identification   29 (100%) 4 (14%) 25 (86%) 0 

Knowledge application 5 (17%) 22 (76%) 2 (7%) 14 (48%) 15 (52%) 0 

Knowledge Sharing and 

Transfer 
2 (7%) 24 (83%) 3 (10%) 9 (31%) 20 (69%) 0 

Knowledge repository 5 (17%) 22 (76%) 2 (7%) 13 (45%) 16 (55%) 0 

Intervention     

Knowledge identification 0 20 (69%) 9 (31%) 5 (17%) 24 (83%) 0 

Knowledge application 7 (24%) 22 (76%) 0 14 (48%) 15 (52%) 0 

Knowledge Sharing and 

Transfer 
6 (21%) 21 (72%) 2 (7%) 7 (24%) 22 (76%) 0 

Knowledge repository 5 (17%) 18 (62%) 6 (21%) 7 (24%) 22 (76%) 0 

Implementation     

Knowledge identification 17 (59%) 12 (41%) 0 18 (62%) 11 (38%) 0 

Knowledge application 6 (21%) 23 (79%) 2 (7%) 28 (97%) 1 (3%) 0 

Knowledge Sharing and 

Transfer 
5 (17%) 22 (76%) 2 (7%) 6 (21%) 23 (79%) 0 

Knowledge repository 12 (41%) 17 (59%) 0 14 (48%) 15 (52%) 0 

Evaluation     

Knowledge identification 0 0 29 (100%) 5 (17%) 24 (83%) 0 

Knowledge application 0 0 29 (100%) 8 (28%) 21 (72%) 0 

Knowledge Sharing and 

Transfer 
0 1 (3%) 28 (97%) 10 (34%) 19 (66%) 0 

Knowledge repository 0 0 29 (100%) 10 (34%) 19 (66%) 0 

 

Table 6. Statistical analysis of pre and post  intervention between adverse event and near missed 

 

 ∆ – SD Z Asymp. Sig (2-tailed) 

Advers event 0.15 ± 0 2.023 0.043 

Near missed 89.08 ± 3.78 4.703 0.000 

Results of statistical analysis of the near 

missed by using Wilcoxon Signed Rank test 

showed a significance value (p) = 0.000, less 

than the standard value of α = 0.05 which 

indicates that there is an influence of 

medication error prevention knowledge 



Preventing Medication Error Based on Knowledge Management (Apriyani Puji H. et.al) 

139 

 

management based on the nearly missed 

incident. While the results of the statistical 

analysis of the adverse event by using 

Wilcoxon Signed Rank Test showed 

significance value (p) = 0.043, less than the 

standard value of α = 0.05 which indicates that 

there is the influence of medication error 

prevention-based on knowledge management 

against the adverse event. 

 

DISCUSSION 

Individual Factors Against the 

Prevention of Medication Error Based on 

Knowledge Management 

 The results of PLS analysis obtained that 

the coefficient value of 0.56 lines and 4,671 t 

statistic (t> 1.96). It can be concluded that 

individual factors contribute to the adoption of 

knowledge management-based medication 

error and indirectly an attempt to reduce the 

adverse event. Components of the individual 

factors include knowledge, abilities, skills of 

nurses, and psychological. Mc. Closhey & Mc. 

Cain (1988) research results which cited in 

Gillies (2004) stated that nurses who have 

higher education also have the ability to work 

better. Efforts to increase knowledge is an 

important thing especially in the context of 

patient safety. Human resource-limited 

knowledge was health services problem to 

unable manage service-oriented based on 

patient safety which is a required key for the 

sake of security created by the care given by 

health workers, including nurses. 

In this case, the ability and skills of 

nurses related to the implementation of the 

drugs correct administration principles 

conducted by nurses include right patient, right 

drug, right indication, right dose, right route of 

administration, the correct time and the correct 

documentation. 

Psychological factors include 

perception, motivation, attitude and 

willingness to learn. Perception in this case 

related to the satisfaction of nurses to the 

salary given by the health services. The 

motivation of nurse to maintain patient safety 

efforts and motivation of the leadership that 

made more development in work. The attitude 

and willingness to learn make nurses more 

responsible for their actions. Their high 

willingness to study of RSUI nurses thus 

requiring hospital organization active role as a 

media to conduct information and knowledge for 

nurses. 

Organization Factors Against the Prevention 

of Medication Error Based on Knowledge 

Management 

The study results, the analysis of PLS 

obtained coefficient t statistic lines 0276 and 

2504 (t> 1.96), these results suggest that there 

is significant influence between the variables 

of organizational factors on medication error 

prevention-based knowledge management. 

Organization factors have sub-variables 

included organizational commitment, 

leadership, structure, and culture of the 

organization. 

The organization structure shows how a 

group designed, lines of communication and 

relationships of authority and decision-making 

(Marquis & Huston, 2000). Organization 

commitment stated here include hospitals 

vision and mission suitability, reward and 

punishment, training and development. RSUI’s 

Vision and the mission were appropriate, 

particularly related to Quality Improvement 

and Patient Safety. Reward and punishment 

imposed by the hospitals, especially in a room 

with a patient safety incident reporting 

implemented by regularly documented every 

week and every month. Currently, nurses in the 

hospitals are still got no reward and 

punishment in particular, but every month 

there is a favorite nurse election based on a 

poll of the patient. Training and development 

at RSUI were based on their regular schedule 

in the improvement of knowledge especially 

nurses with information in the form of in-

house training with the involvement of the 

expert of experts according to the field or 

socialization by peers who have been carrying 

out training of ex-house training. 

Instruction model leadership is indicated 

by the high task and low relationship. RSUI 

leadership has contributed greatly to the 

compliance of nurses in implementing guidelines 

for prevention of medication errors. This is 

consistent with the theory that nurse manager has 

a very important role in implementing patient 

safety, especially the prevention of medication 

errors. In other research, any correlation between 

nurse’s knowledge levels with right principle 

implementation of medication on injection action 

(Gede, Pratama, Prabowo, & Rahil, n.d.)  

The organization system in RSUI was well 

structured so that the chain of command and 



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140 

 

coordination lines between each field can be 

implemented quite well. Given the structure of 

a good organization can support nurse 

adherence in doing medication error 

prevention. 

Work characteristic Against the 

Prevention of Medication Error Based on 

Knowledge Management 

The results of PLS analysis obtained 

coefficient lines 0309 and t statistic is 1.98 (t> 

1.96). This showed that there is significant 

influence between variable factors, work 

characteristic against the prevention of medication 

errors based knowledge management. Further 

found also showed that the objective 

performance is a domain factor related to 

nursing compliance in applying the prevention 

of medication errors. 

Robbin (2008) stated that a work 

characteristic is an approach to work that is 

specified in 5 dimensions of the core 

characteristics: skill variety, task identity, task 

significance, autonomy, and feedback.  

In RSUI Malang district, job design 

delivered at the beginning of nurse orientation 

after they accepted as a nurse. Nurses are 

oriented about their responsibilities, rights, and 

duties as a nurse at the hospital. This activity is 

closely related to job performance, and 

supervision carried out by hospitals, but this 

activity still does not yet implemented 

optimally. Therefore, the hospital should 

perform evaluation and amelioration of 

performance and supervision. 

Implementation of Medication Error 

Prevention - Based on Knowledge 

Management against Adverse Event 

The trial model of knowledge-based 

prevention of medication errors management 

as an effort to decrease the adverse event of 4 

modules that have been tested to decrease the 

adverse event. The significant difference is the 

inaccuracy of time and documentation, where 

nurses do not realize the impact that may arise 

in the administration of drugs that do not 

correspond with the timing so that the next 

shift could be faster or slower administer the 

drugs so it can influence the effectiveness of 

drug delivery. 

Based on the overall hypothesis testing, 

it can be seen significant lines, models 

describing these results is the variable of 

individuals ability, organizations and work 

characteristic variable against the prevention of 

medication errors based knowledge 

management and indirectly to decrease the 

adverse event.  

 

CONCLUSIONS  

Individual factors (demographics data, 

level of knowledge, abilities, and skills, and 

psychological) significantly influence on the 

prevention of medication errors based on 

knowledge management. While organizational 

factors (organizational commitment, 

leadership, structure, and organizational 

culture) significantly affect the prevention of 

medication errors based on knowledge 

management. Job characteristic factors 

(objective performance and feedback) 

significantly influence the medication error 

prevention-based knowledge management. 

Model of medication error prevention-

based on knowledge management is influenced 

by individual factors, organization and work 

characteristic. Medication error prevention-

based knowledge management can 

significantly reduce the unexpected incidence. 

Learning with knowledge management 

methods are used so that the nurse can learn 

about discussion, formulate, and decide on 

knowledge gained so can be easily applied to 

the ability of nurses in drug delivery. 

To enhance the prevention of medication 

error, it needs to make a list of the order of 

nursing personnel who will participate in 

continuing education, training or seminars as a 

form of nursing staff’s knowledge increase. 

Application of medication error prevention 

module-based on knowledge management can 

be performed on orientation activities at the 

first time of nurse work. Create pre-conference 

and post-conference activities routine at every 

turn shift as a medium to add information and 

knowledge for nurses. Create continue 

evaluation and supervision for nurses to 

conduct the safe administration of drugs and as 

an effort to improve the behavior of the nurses. 

Enable the nursing committee specifically to 

credentialing about the nurse actions. Initiate 

PMKP program proactively that spurred the 

realization of a work culture toward patient 

safety oriented. Hold a gradual guidance and 

training for nurses who still have less working 

period regarding its implementation about the 

hospital's patient safety. 

 

  



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141 

 

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https://doi.org/10.1016/j.jen.2011.05.003