ANALISIS FAKTOR YANG MEMPENGARUHI PELAPORAN INSIDEN KESELAMATAN PASIEN DI RS MATA JEC-CANDI, SEMARANG
Analysis of Factors Affecting Patient Safety Incident Reporting at JEC-CANDI, Eye Hospital Semarang
Keywords:
Individual Factors, Team Factors, Organizational Factors, Patient Safety Incident Reporting, Patient Safety
Abstract
Background: The Patient Safety Incident (PSI) reporting system is a recommended method for enhancing patient safety, and it has been implemented by hospitals. However, the reporting rate of PSI remains low.
Objectives: This study aims to analyze the impact of individual, team, and organizational factors on PSI reporting at JEC-Candi, Semarang eye hospital and to develop recommendations to improve PSI reporting.
Methods: A mixed-methods sequential explanatory design was used. Quantitative data were obtained through a cross-sectional questionnaire survey and analytical observations using secondary data. Qualitative data were gathered from focus group discussion (FGD) with four separate groups: daily practitioner doctors, daily practitioner healthcare workers, daily practitioner non-healthcare workers, and managerial staff. Quantitative data were analyzed using chi-square or Fisher's exact tests and multivariate logistic regression, while qualitative data were analyzed using thematic analysis.
Results: The study involved 85 subjects for the quantitative study and 25 subjects for the qualitative study. Individual factors (knowledge and motivation), team factors (teamwork), and organizational factors (feedback) significantly influenced PSI reporting (p<0.005). Motivation emerged as the most dominant factor influencing PSI reporting (p=0.008; OR 47.294; CI 95% 2.678-835.190). The qualitative results provided several recommendations for improving PSI reporting, including regular socialization and training, patient safety awareness campaigns, selecting patient safety champions, establishing reward and incentive systems, organizing team-building and cross-unit collaborative activities, and improving access to PSI reporting feedback information.
Conclusions: Individual, team, and organizational factors significantly influence PSI reporting. Therefore, management should implement the recommended strategies to enhance patient safety and quality in the hospital.
References
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37. Evans SM, Smith BJ, Esterman A, Runciman WB, Maddern G, Stead K, et al. Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals. Qual Saf Heal Care. 2007;16:169–75.
38. Engeda EH. Incident Reporting Behaviours and Associated Factors among Nurses Working in Gondar University Comprehensive Specialized Hospital , Northwest Ethiopia. Hindawi Publ Corp Sci. 2016;2016:1–7.
39. Hwang J, Lee S, Park H. Barriers to the Operation of Patient Safety Incident Reporting Systems in Korean General Hospitals. Healthc Inform Res. 2012;18(4):279–86.
40. Tasbun F, Sanjaya GY, Djasri H, St RSU, Sambas E, Barat K, et al. EFEKTIVITAS MODIFIKASI PROGRAM PELATIHAN KESELAMATAN PASIEN TERHADAP PELAKSANAAN PELAPORAN INSIDEN KESELAMATAN PASIEN DI INSTALASI GAWAT DARURAT RSU ST. ELISABETH SAMBAS. J Hosp Acreditation. 2022;04(2):65–9.
41. Alshammari FM, Alanazi EJ, Alanazi AM, Alturifi, Abdulrahman KAlshammari TM. Medication Error Concept and Reporting Practices in Saudi Arabia : A Multiregional Study Among Healthcare Professionals. Risk Manag Healthc Policy. 2021;(14):2395–406.
42. Fukuda H, Imanaka Y, Hirose M, Hayashida K. Impact of system-level activities and reporting design on the number of incident reports for patient safety. Qual Saf Heal Care. 2010;19:122–7.
43. Lambrinos A, Holubowich C. ONTARIO HEALTH TECHNOLOGY Patient Safety Learning Systems : A Systematic Review and Qualitative Synthesis. Ont Health Technol Assess Ser. 2017;17(3):1–23.
44. Turner DA, Bae J, Milne J, Owens TA, Kuhn CM. Improving Resident and Fellow Engagement in Patient Safety Through a Graduate Medical Education Incentive Program. J Grad Med Educ. 2018;671–5.
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46. Buljac-samardzic M, Doekhie KD, Wijngaarden JDH Van. Interventions to improve team effectiveness within health care : a systematic review of the past decade. Hum Resour Health. 2020;18(2):1–42.
2. Mohammed F, Taddele M, Gualu T. Patient safety culture and associated factors among health care professionals at public hospitals in Dessie town, north east Ethiopia, 2019. PLoS One. 2021;16(2 February):1–9.
3. National Academies of Sciences Engineering and Medicine. Crossing the global quality chasm: Improving health care worldwide. Washington, DC: The National Academies Press. 2018. 203–225 p.
4. Salmasi S, Khan TM, Hong YH, Ming LC, Wong TW. Medication errors in the Southeast Asian countries: A systematic review. PLoS One. 2015;10(9):1–19.
5. Wong SC, Kelly SP, Sullivan PM. Patient safety in vitreoretinal surgery: Quality improvements following a patient safety reporting system. Br J Ophthalmol. 2013;97(3):302–7.
6. Wilson McL. R, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The quality in Australian health care study. Med J Aust. 1995;163(9):458–71.
7. Steeples LR, Hingorani M, Flanagan D, Kelly SP. Wrong intraocular lens events - What lessons have we learned? A review of incidents reported to the National Reporting and Learning System: 2010-2014 versus 2003-2010. Eye. 2016;30(8):1049–55.
8. AlBlaihed RM, AlSaeed MI, Abuabat AA, Ahsan SH. Incident reporting in dentistry: Clinical supervisor’s awareness, practice and perceived barriers. Eur J Dent Educ. 2018;22(3):e408–18.
9. Naome T, James M, Christine A, Mugisha TI. Practice, perceived barriers and motivating factors to medical-incident reporting: A cross-section survey of health care providers at Mbarara regional referral hospital, southwestern Uganda. BMC Health Serv Res. 2020;20(1):1–9.
10. Oweidat I, Al-Mugheed K, Alsenany SA, Abdelaliem SMF, Alzoubi MM. Awareness of reporting practices and barriers to incident reporting among nurses. BMC Nurs. 2023;22(1):1–10.
11. Bolarinwa OA. Principles and methods of validity and reliability testing of questionnaires used in social and health science researches. 2016;(January).
12. Jeske D, Olson D. Silo mentality in teams: emergence, repercussions and recommended options for change. J Work Manag. 2024;
13. Yuniati F, Kamso S. Assessing the Quality of Life Among Productive Age in the General Population: A Cross-Sectional Study of Family Life Survey in Indonesia. Asia-Pacific J Public Heal. 2021;33(1):53–9.
14. Karanika-Murray M, Veldhoven M Van, Michaelides G, Baguley T, Gkiontsi D, Harrison N. Curvilinear Relationships Between Age and Job Performance and the Role of Job Complexity. Work Aging Retire. 2024;10(2):156–73.
15. Crimi C, Carlucci A. Challanges for the female health-care workers during the COVID-19 pandemic: the need for protection beyond the mask. Pulmonology. 2021;27(January):1–3.
16. WHO. Gender Equity In The Health Workforce: Analysis of 104 Countries. World Heal Organ. 2019;(March):1–8.
17. Abdelrahman SM, Abdelkader AM. Attitudes of Both Male and Female Nurses toward Men in Nursing in Minia University Hospital. IOSR J Res Method Educ. 2016;6(6):46–55.
18. Adriansyah AA, Setianto B, Lestari I, Arindis P, Kurniawana W, Nikmatus S. Incident analysis of patient safety in hospital : Based on feedback and supervision concept. Bali Med J. 2022;11(2):665–70.
19. Dhamanti I, Leggat S, Barraclough S. Practical and cultural barriers to reporting incidents among health workers in Indonesian public hospitals. J Multidiscip Healthc. 2020;13:351–9.
20. Shemsu A, Dechasa A, Ayana M, Tura MR. Patient safety incident reporting behavior and its associated factors among healthcare professionals in Hadiya zone, Ethiopia: A facility based cross-sectional study. Int J Nurs Stud Adv. 2024;6(May):100209.
21. Suangga F, Tuppal CP. Motivation among Indonesian Nurses in Pursuing Continuing Professional Education and Its Relationship to Their Competencies. Nurse Media J Nurs. 2017;7(1):24–34.
22. Pakpahan M, Siregar D, Susilawaty A, Mustar T, Ramdany R, Indah ME. Promosi Kesehatan & Perilaku Kesehatan. 1st ed. Watrianthos R, editor. Jakarta: EGC. Yayasan Kita Menulis; 2021.
23. Tage PKS, Berkanis AT, Betan Y, Pinis AEB. A Qualitative Study on Nurses’ Experiences of Reporting Patient Safety Incidents in East Nusa Tenggara, Indonesia. Nurse Media J Nurs. 2021;11(3):359–69.
24. Parlupi, Suroso A, Sutrisna E. PATIENT SAFETY CULTURE AND ITS DETERMINING FACTORS ( A QUALITATIVE STUDY AT ISLAMIC HOSPITAL OF BANJARNEGARA ( RSI BANJARNEGARA ). Int Sustain Compet Advant. 2020;(1):1–9.
25. Kousgaard MBØM, Joensen AS, Thorsen T. Reasons for not reporting patient safety incidents in general practice : A qualitative study. Scand J Prim Health Care. 2012;30:199–205.
26. Anderson JE, Kodate N, Walters R, Dodds A. Can incident reporting improve safety ? Healthcare practitioners ’ views of the effectiveness of incident reporting. Int J Qual Heal Care. 2013;25(2):141–50.
27. Alsafi E, Baharoon S, Ahmed A, Zahrani S Al, Sayyari A Al. Physicians ’ knowledge and practice towards medical error reporting : a cross-sectional hospital-based study in Saudi Arabia. East Mediterr Heal J. 2015;21(9):655–64.
28. Meifika Fathiyani G, Ayubi D. Factors Affecting Patient Safety Incident Reporting. J Res Soc Sci Econ Manag. 2022;1(8):1103–17.
29. Isaksson S, Schwarz A, Rusner M, Nordström S, Källman U. Monitoring Preventable Adverse Events and Near Misses : Number and Type Identified Differ Depending on. J Patient Saf. 2022;18(4):325–30.
30. Shin S, Won M. Trend Analysis of Patient Safety Incidents and Their Associated Factors in Korea Using National Patient Safety Report Data (2017~2019). Int J Environ Res Public Health. 2021;18(8482):1–11.
31. Archer S, Hull L, Soukup T, Mayer E, Athanasiou T, Sevdalis N, et al. Development of a theoretical framework of factors affecting patient safety incident reporting: A theoretical review of the literature. BMJ Open. 2017;7(12).
32. Adyani NLGS, Nugraha INA, Rudiartha IGLM. Evaluasi pelaporan insiden keselamatan pasien di rumah sakit umum daerah karangasem. J Ilm Keperawatan. 2022;8(4).
33. Patterson ME, Pace HA. A Cross-sectional Analysis Investigating Organizational Factors That Influence Near-Miss Error Reporting Among Hospital Pharmacists. J Patient Saf. 2016;12(2):114–7.
34. Howell A, Burns EM, Bouras G, Donaldson LJ, Athanasiou T, Darzi A. Can Patient Safety Incident Reports Be Used to Compare Hospital Safety ? Results from a Quantitative Analysis of the English National Reporting and Learning System Data. PLoS One. 2015;61:1–15.
35. Hotton E, Jordan L, Peden C. Improving incident reporting among junior doctors. BMJ Qual Improv Reports. 2014;1–4.
36. Parmelli E, Flodgren G, Sg F, Williams N, Rubin G, Mp E. Interventions to increase clinical incident reporting in health care (Review). Cochrane Database Syst Rev. 2012;(8).
37. Evans SM, Smith BJ, Esterman A, Runciman WB, Maddern G, Stead K, et al. Evaluation of an intervention aimed at improving voluntary incident reporting in hospitals. Qual Saf Heal Care. 2007;16:169–75.
38. Engeda EH. Incident Reporting Behaviours and Associated Factors among Nurses Working in Gondar University Comprehensive Specialized Hospital , Northwest Ethiopia. Hindawi Publ Corp Sci. 2016;2016:1–7.
39. Hwang J, Lee S, Park H. Barriers to the Operation of Patient Safety Incident Reporting Systems in Korean General Hospitals. Healthc Inform Res. 2012;18(4):279–86.
40. Tasbun F, Sanjaya GY, Djasri H, St RSU, Sambas E, Barat K, et al. EFEKTIVITAS MODIFIKASI PROGRAM PELATIHAN KESELAMATAN PASIEN TERHADAP PELAKSANAAN PELAPORAN INSIDEN KESELAMATAN PASIEN DI INSTALASI GAWAT DARURAT RSU ST. ELISABETH SAMBAS. J Hosp Acreditation. 2022;04(2):65–9.
41. Alshammari FM, Alanazi EJ, Alanazi AM, Alturifi, Abdulrahman KAlshammari TM. Medication Error Concept and Reporting Practices in Saudi Arabia : A Multiregional Study Among Healthcare Professionals. Risk Manag Healthc Policy. 2021;(14):2395–406.
42. Fukuda H, Imanaka Y, Hirose M, Hayashida K. Impact of system-level activities and reporting design on the number of incident reports for patient safety. Qual Saf Heal Care. 2010;19:122–7.
43. Lambrinos A, Holubowich C. ONTARIO HEALTH TECHNOLOGY Patient Safety Learning Systems : A Systematic Review and Qualitative Synthesis. Ont Health Technol Assess Ser. 2017;17(3):1–23.
44. Turner DA, Bae J, Milne J, Owens TA, Kuhn CM. Improving Resident and Fellow Engagement in Patient Safety Through a Graduate Medical Education Incentive Program. J Grad Med Educ. 2018;671–5.
45. Herzer KR, Mirrer M, Xie Y, Steppan J, Jung C, Cover R, et al. Patient Safety Reporting Systems: Sustained Quality Improvement Using a Multidisciplinary Team and “Good Catch” Awards. J Qual Patient Saf. 2012;38(8):339–47.
46. Buljac-samardzic M, Doekhie KD, Wijngaarden JDH Van. Interventions to improve team effectiveness within health care : a systematic review of the past decade. Hum Resour Health. 2020;18(2):1–42.
Published
2025-10-06
How to Cite
Uswatunnisa Arfiningtyas, Djasri, H., & Bismantara, H. (2025). ANALISIS FAKTOR YANG MEMPENGARUHI PELAPORAN INSIDEN KESELAMATAN PASIEN DI RS MATA JEC-CANDI, SEMARANG. Jurnal Manajemen Pelayanan Kesehatan (The Indonesian Journal of Health Service Management), 28(03), 77-91. https://doi.org/10.22146/jmpk.v28i03.17262
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