Nurses Perspectives Causes And Management Strategies To Prevent Medication Errors: Qualitative Study

https://doi.org/10.35912/jakman.v7i1.4771
Published: Dec 2, 2025

Abstract:

Purpose: This study aims to explore the causes of medication errors, prevention strategies, and the role of hospital management in reducing such errors, based on the perceptions of nurses.

Methodology/approach: This qualitative research used a thematic analysis approach and was conducted at a private hospital in Surabaya. Data were collected through in-depth interviews with 10 informants—7 shift-leading nurses and 3 head nurses—who met the inclusion criteria. MAXQDA Pro 2024 was used for data coding and analysis. The analysis process included transcription, initial coding, theme development, and interpretation based on Lincoln and Guba’s trustworthiness criteria.

Results/findings:The main causes of medication error were identified as lack of double-checking, crowded work environments, poor documentation, communication issues, and limited experience. Prevention strategies included implementation of double-check procedures, communication improvement, regular training, and integration of technology. Management roles such as supervision, SOP revision, and Root Cause Analysis (RCA) were essential in supporting safe medication practices.

Conclusions: Management's role is considered crucial in establishing a system that supports patient safety through policies such as supervision, training, SOP revisions, and conducting Root Cause Analysis (RCA) for any unforeseen incidents, thereby ensuring that the implemented nursing management strategies become more effective and efficient.

Limitations: This study is limited to one hospital with a small number of participants and does not include perspectives from other healthcare professionals like pharmacists or physicians.

Contribution: The study contributes to patient safety literature and provides actionable insights for hospital administrators, nurse managers, and healthcare policymakers to improve medication safety.

Keywords:
1. Double Check
2. Medication Error
3. Nurse Perception
4. Patient Safety
5. Thematic Analysis
Authors:
1 . Martha Sasmita Ningrum
2 . Jovita Irawati
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How to Cite
Ningrum, M. S., & Irawati, J. . (2025). Nurses Perspectives Causes And Management Strategies To Prevent Medication Errors: Qualitative Study . Jurnal Akuntansi, Keuangan, Dan Manajemen, 7(1), 15–28. https://doi.org/10.35912/jakman.v7i1.4771
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Vol. 7 No. 1 (2025): Desember
Articles
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References

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    Antariksa, S. K. S. (2025). Emotional Intelligence, Leadership Effectiveness, and Team Performance: Synergies in Human Resource Development. Jurnal Akuntansi, Keuangan, dan Manajemen, 6(3), 659-668. doi:https://doi.org/10.35912/jakman.v6i3.3617

    Arakawa, C., Kanoya, Y., & Sato, C. (2011). Factors contributing to medical errors and incidents among hospital nurses—nurses’ health, quality of life, and workplace predict medical errors and incidents—. Industrial health, 49(3), 381-388. doi:https://doi.org/10.2486/indhealth.MS968

    Ariyanti, S., Ilmy, S. K., Tinungki, Y. L., Yanti, N. P. E. D., Juwariyah, S., Waras, N. G. T., . . . Lating, Z. (2023). Keselamatan Pasien dan Keselamatan Kesehatan Kerja: PT. Sonpedia Publishing Indonesia.

    Aronson, J. K. (2009). Medication errors: definitions and classification. British journal of clinical pharmacology, 67(6), 599-604. doi:https://doi.org/10.1111/j.1365-2125.2009.03415.x

    Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), 77-101. doi:https://doi.org/10.1191/1478088706qp063oa

    Davis, T. R., Straatmann, K., Snyder, N., Shiner, D., Evans, A., Caruso, C., & Alton, M. (2025). Promoting a Culture of Patient Safety: Using the Principles of Just Culture to Improve Transparency and Risk Reporting in the Hospital Setting. PATIENT SAFETY, 7(2). doi:https://doi.org/10.33940/001c.137737

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    Douglass, A. M., Elder, J., Watson, R., Kallay, T., Kirsh, D., Robb, W. G., . . . Coil, C. J. (2018). A randomized controlled trial on the effect of a double check on the detection of medication errors. Annals of emergency medicine, 71(1), 74-82. e71. doi:https://doi.org/10.1016/j.annemergmed.2017.03.022

    Doyle, L., McCabe, C., Keogh, B., Brady, A., & McCann, M. (2020). An overview of the qualitative descriptive design within nursing research. Journal of research in nursing, 25(5), 443-455. doi:https://doi.org/10.1177/1744987119880234

    Erisusanto, R., Satriawan, B., & Khaddafi, M. (2025). Pengaruh IQ, Pengalaman, Perilaku & Motivasi terhadap Kinerja Pegawai Pemerintah Kabupaten Karimun. Studi Ilmu Manajemen dan Organisasi, 6(1), 279-291. doi:https://doi.org/10.35912/simo.v6i1.3531

    Farag, A., Lose, D., & Gedney-Lose, A. (2019). Nurses’ safety motivation: examining predictors of nurses’ willingness to report medication errors. Western journal of nursing research, 41(7), 954-972. doi:https://doi.org/10.1177/0193945918815462

    Gebremariam, S. N., Sema, F. D., Jara, A. G., Mekonen, B. T., & Mekonnen, G. A. (2023). Medication error and associated factors among adults admitted to emergency ward at the university of Gondar comprehensive specialized hospital, North-West Ethiopia: a cross-sectional study, 2022. Journal of Pharmaceutical Policy and Practice, 16(1), 148.

    Hairudin, H., & Oktaria, E. T. (2022). Analisis Peningkatan Kinerja Karyawan melalui Motivasi Kerja Internal dan Motivasi Eksternal Karyawan. Jurnal Akuntansi, Keuangan, dan Manajemen, 4(1), 1-14. doi:https://doi.org/10.35912/jakman.v4i1.1466

    Hariyati, R. T. S., Mediawati, A. S., & Eryando, T. (2021). Workload as the most important influencing factor of medication errors by nurses. The Open Nursing Journal, 15(1). doi:http://dx.doi.org/10.2174/1874434602115010204

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    Irawati, J. (2019). Inkonsistensi Regulasi Di Bidang Kesehatan Dan Implikasi Hukumnya Terhadap Penyelesaian Perkara Medik Di Indonesia. Law Review, 54-76.

    Kabusi, M., & Yazdi, K. (2024). Nursing process based on Betty Neuman's systemic model: A case study. Journal of Nursing Advances in Clinical Sciences, 1(2), 111-117. doi:https://doi.org/10.32598/JNACS.2403.1011

    Li, L. Z., Yang, P., Singer, S. J., Pfeffer, J., Mathur, M. B., & Shanafelt, T. (2024). Nurse burnout and patient safety, satisfaction, and quality of care: a systematic review and meta-analysis. JAMA network open, 7(11), e2443059-e2443059. doi:https://doi.org/10.1001/jamanetworkopen.2024.43059

    Lincoln, Y. S., Lynham, S. A., & Guba, E. G. (2011). Paradigmatic controversies, contradictions, and emerging confluences, revisited. The Sage handbook of qualitative research, 4(2), 97-128.

    Luthfiana, H., & Rianto, M. R. (2023). Literature Review terhadap Kepuasan Kerja: Pengaruh Komunikasi dan Lingkungan Kerja. Studi Ilmu Manajemen dan Organisasi, 4(1), 27-37. doi:https://doi.org/10.35912/simo.v4i1.1729

    Mekarisce, A. A. (2020). Teknik pemeriksaan keabsahan data pada penelitian kualitatif di bidang kesehatan masyarakat. Jurnal Ilmiah Kesehatan Masyarakat: Media Komunikasi Komunitas Kesehatan Masyarakat, 12(3), 145-151. doi:https://doi.org/10.52022/jikm.v12i3.102

    Moeljatno. (2008). Asas-asas Hukum Pidana (Revisi ed.). Jakarta Rineka Cipta.

    Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., . . . Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines, 8(9), 46. doi:https://doi.org/10.3390/medicines8090046

    Payne, R., Slight, S., Franklin, B. D., & Avery, A. J. (2016). Medication errors: World Health Organization.

    Prakoso, A., & Budiono, A. (2025). Understanding Employee Turnover: Health, Safety, Work Environment, and Job Satisfaction Influence Commitment. Jurnal Akuntansi, Keuangan, dan Manajemen, 6(3), 815-826. doi:https://doi.org/10.35912/jakman.v6i3.4585

    Rogers, E., Griffin, E., Carnie, W., Melucci, J., & Weber, R. J. (2017). A just culture approach to managing medication errors. Hospital pharmacy, 52(4), 308-315. doi:https://doi.org/10.1310/hpj5204-308

    Ryan, R. M., & Deci, E. L. (2000). When rewards compete with nature: The undermining of intrinsic motivation and self-regulation Intrinsic and extrinsic motivation (pp. 13-54): Elsevier.

    Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: a qualitative study. International Journal of Africa Nursing Sciences, 13, 100235. doi:https://doi.org/10.1016/j.ijans.2020.100235

    Schelbred, A. B., & Nord, R. (2007). Nurses’ experiences of drug administration errors. Journal of advanced nursing, 60(3), 317-324. doi:https://doi.org/10.1111/j.1365-2648.2007.04437.x

    Sutantyo, A. (2016). Malpraktik dan Pertanggungjawaban Hukum Tenaga Medis: Pustaka Pelajar.

    Veenstra, G. L., Dabekaussen, K. F., Molleman, E., Heineman, E., & Welker, G. A. (2022). Health care professionals’ motivation, their behaviors, and the quality of hospital care: A mixed-methods systematic review. Health care management review, 47(2), 155-167. doi: https://doi.org/10.1097/HMR.0000000000000284

    Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC nursing, 19(1), 4. doi:https://doi.org/10.1186/s12912-020-0397-0

    Xie, N., Kalia, K., Strudwick, G., & Lau, F. (2019). Understanding mental health nurses’ perceptions of barcode medication administration: a qualitative descriptive study. Issues in Mental Health Nursing, 40(4), 326-334. doi:https://doi.org/10.1080/01612840.2018.1528321

    Yang, L., Peng, X., Song, W., Su, H., Wang, C., Yang, S., & Wu, D. (2025). The barriers to medication error reporting by nurses and factors associated with it: a cross-sectional study in a tertiary hospital of south-west China. BMJ open, 15(4), e091058. doi:https://doi.org/10.1136/bmjopen-2024-091058

    Y?lmaz, A., & Sönmez, B. (2024). Nurses' perspectives and experiences on medical errors: A qualitative study. Journal of Evaluation in Clinical Practice, 30(6), 1153-1164. doi:https://doi.org/10.1111/jep.14125

    Zewien, H. T., Abed, F. A., & Bayoumy, S. A. (2022). Relationship between nursing supervision and the incidence of medication administration errors. Egyptian Nursing Journal, 19(2), 97-105. doi:https://doi.org/10.4103/enj.enj_36_21

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  3. Arakawa, C., Kanoya, Y., & Sato, C. (2011). Factors contributing to medical errors and incidents among hospital nurses—nurses’ health, quality of life, and workplace predict medical errors and incidents—. Industrial health, 49(3), 381-388. doi:https://doi.org/10.2486/indhealth.MS968
  4. Ariyanti, S., Ilmy, S. K., Tinungki, Y. L., Yanti, N. P. E. D., Juwariyah, S., Waras, N. G. T., . . . Lating, Z. (2023). Keselamatan Pasien dan Keselamatan Kesehatan Kerja: PT. Sonpedia Publishing Indonesia.
  5. Aronson, J. K. (2009). Medication errors: definitions and classification. British journal of clinical pharmacology, 67(6), 599-604. doi:https://doi.org/10.1111/j.1365-2125.2009.03415.x
  6. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative research in psychology, 3(2), 77-101. doi:https://doi.org/10.1191/1478088706qp063oa
  7. Davis, T. R., Straatmann, K., Snyder, N., Shiner, D., Evans, A., Caruso, C., & Alton, M. (2025). Promoting a Culture of Patient Safety: Using the Principles of Just Culture to Improve Transparency and Risk Reporting in the Hospital Setting. PATIENT SAFETY, 7(2). doi:https://doi.org/10.33940/001c.137737
  8. Diniz, J. d. S. P., Batista, K. d. M., Luciano, L. d. S., Fioresi, M., Amorim, M. H. C., & Bringuente, M. E. d. O. (2019). Nursing intervention based on Neuman's theory and mediated by an educational game. Acta Paulista de Enfermagem, 32, 600-607. doi:https://doi.org/10.1590/1982-0194201900084
  9. Douglass, A. M., Elder, J., Watson, R., Kallay, T., Kirsh, D., Robb, W. G., . . . Coil, C. J. (2018). A randomized controlled trial on the effect of a double check on the detection of medication errors. Annals of emergency medicine, 71(1), 74-82. e71. doi:https://doi.org/10.1016/j.annemergmed.2017.03.022
  10. Doyle, L., McCabe, C., Keogh, B., Brady, A., & McCann, M. (2020). An overview of the qualitative descriptive design within nursing research. Journal of research in nursing, 25(5), 443-455. doi:https://doi.org/10.1177/1744987119880234
  11. Erisusanto, R., Satriawan, B., & Khaddafi, M. (2025). Pengaruh IQ, Pengalaman, Perilaku & Motivasi terhadap Kinerja Pegawai Pemerintah Kabupaten Karimun. Studi Ilmu Manajemen dan Organisasi, 6(1), 279-291. doi:https://doi.org/10.35912/simo.v6i1.3531
  12. Farag, A., Lose, D., & Gedney-Lose, A. (2019). Nurses’ safety motivation: examining predictors of nurses’ willingness to report medication errors. Western journal of nursing research, 41(7), 954-972. doi:https://doi.org/10.1177/0193945918815462
  13. Gebremariam, S. N., Sema, F. D., Jara, A. G., Mekonen, B. T., & Mekonnen, G. A. (2023). Medication error and associated factors among adults admitted to emergency ward at the university of Gondar comprehensive specialized hospital, North-West Ethiopia: a cross-sectional study, 2022. Journal of Pharmaceutical Policy and Practice, 16(1), 148.
  14. Hairudin, H., & Oktaria, E. T. (2022). Analisis Peningkatan Kinerja Karyawan melalui Motivasi Kerja Internal dan Motivasi Eksternal Karyawan. Jurnal Akuntansi, Keuangan, dan Manajemen, 4(1), 1-14. doi:https://doi.org/10.35912/jakman.v4i1.1466
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  17. Irawati, J. (2019). Inkonsistensi Regulasi Di Bidang Kesehatan Dan Implikasi Hukumnya Terhadap Penyelesaian Perkara Medik Di Indonesia. Law Review, 54-76.
  18. Kabusi, M., & Yazdi, K. (2024). Nursing process based on Betty Neuman's systemic model: A case study. Journal of Nursing Advances in Clinical Sciences, 1(2), 111-117. doi:https://doi.org/10.32598/JNACS.2403.1011
  19. Li, L. Z., Yang, P., Singer, S. J., Pfeffer, J., Mathur, M. B., & Shanafelt, T. (2024). Nurse burnout and patient safety, satisfaction, and quality of care: a systematic review and meta-analysis. JAMA network open, 7(11), e2443059-e2443059. doi:https://doi.org/10.1001/jamanetworkopen.2024.43059
  20. Lincoln, Y. S., Lynham, S. A., & Guba, E. G. (2011). Paradigmatic controversies, contradictions, and emerging confluences, revisited. The Sage handbook of qualitative research, 4(2), 97-128.
  21. Luthfiana, H., & Rianto, M. R. (2023). Literature Review terhadap Kepuasan Kerja: Pengaruh Komunikasi dan Lingkungan Kerja. Studi Ilmu Manajemen dan Organisasi, 4(1), 27-37. doi:https://doi.org/10.35912/simo.v4i1.1729
  22. Mekarisce, A. A. (2020). Teknik pemeriksaan keabsahan data pada penelitian kualitatif di bidang kesehatan masyarakat. Jurnal Ilmiah Kesehatan Masyarakat: Media Komunikasi Komunitas Kesehatan Masyarakat, 12(3), 145-151. doi:https://doi.org/10.52022/jikm.v12i3.102
  23. Moeljatno. (2008). Asas-asas Hukum Pidana (Revisi ed.). Jakarta Rineka Cipta.
  24. Mutair, A. A., Alhumaid, S., Shamsan, A., Zaidi, A. R. Z., Mohaini, M. A., Al Mutairi, A., . . . Al-Omari, A. (2021). The effective strategies to avoid medication errors and improving reporting systems. Medicines, 8(9), 46. doi:https://doi.org/10.3390/medicines8090046
  25. Payne, R., Slight, S., Franklin, B. D., & Avery, A. J. (2016). Medication errors: World Health Organization.
  26. Prakoso, A., & Budiono, A. (2025). Understanding Employee Turnover: Health, Safety, Work Environment, and Job Satisfaction Influence Commitment. Jurnal Akuntansi, Keuangan, dan Manajemen, 6(3), 815-826. doi:https://doi.org/10.35912/jakman.v6i3.4585
  27. Rogers, E., Griffin, E., Carnie, W., Melucci, J., & Weber, R. J. (2017). A just culture approach to managing medication errors. Hospital pharmacy, 52(4), 308-315. doi:https://doi.org/10.1310/hpj5204-308
  28. Ryan, R. M., & Deci, E. L. (2000). When rewards compete with nature: The undermining of intrinsic motivation and self-regulation Intrinsic and extrinsic motivation (pp. 13-54): Elsevier.
  29. Salar, A., Kiani, F., & Rezaee, N. (2020). Preventing the medication errors in hospitals: a qualitative study. International Journal of Africa Nursing Sciences, 13, 100235. doi:https://doi.org/10.1016/j.ijans.2020.100235
  30. Schelbred, A. B., & Nord, R. (2007). Nurses’ experiences of drug administration errors. Journal of advanced nursing, 60(3), 317-324. doi:https://doi.org/10.1111/j.1365-2648.2007.04437.x
  31. Sutantyo, A. (2016). Malpraktik dan Pertanggungjawaban Hukum Tenaga Medis: Pustaka Pelajar.
  32. Veenstra, G. L., Dabekaussen, K. F., Molleman, E., Heineman, E., & Welker, G. A. (2022). Health care professionals’ motivation, their behaviors, and the quality of hospital care: A mixed-methods systematic review. Health care management review, 47(2), 155-167. doi: https://doi.org/10.1097/HMR.0000000000000284
  33. Wondmieneh, A., Alemu, W., Tadele, N., & Demis, A. (2020). Medication administration errors and contributing factors among nurses: a cross sectional study in tertiary hospitals, Addis Ababa, Ethiopia. BMC nursing, 19(1), 4. doi:https://doi.org/10.1186/s12912-020-0397-0
  34. Xie, N., Kalia, K., Strudwick, G., & Lau, F. (2019). Understanding mental health nurses’ perceptions of barcode medication administration: a qualitative descriptive study. Issues in Mental Health Nursing, 40(4), 326-334. doi:https://doi.org/10.1080/01612840.2018.1528321
  35. Yang, L., Peng, X., Song, W., Su, H., Wang, C., Yang, S., & Wu, D. (2025). The barriers to medication error reporting by nurses and factors associated with it: a cross-sectional study in a tertiary hospital of south-west China. BMJ open, 15(4), e091058. doi:https://doi.org/10.1136/bmjopen-2024-091058
  36. Y?lmaz, A., & Sönmez, B. (2024). Nurses' perspectives and experiences on medical errors: A qualitative study. Journal of Evaluation in Clinical Practice, 30(6), 1153-1164. doi:https://doi.org/10.1111/jep.14125
  37. Zewien, H. T., Abed, F. A., & Bayoumy, S. A. (2022). Relationship between nursing supervision and the incidence of medication administration errors. Egyptian Nursing Journal, 19(2), 97-105. doi:https://doi.org/10.4103/enj.enj_36_21