Rumah sakit menghadapi berbagai risiko kompleks yang dapat berdampak pada keselamatan pasien dan mutu pelayanan. Risk register merupakan instrumen penting dalam manajemen risiko yang mencatat proses identifikasi, analisis, evaluasi, dan perlakuan risiko secara terstruktur. Namun, temuan di Rumah Sakit Pendidikan Universitas Indonesia (RSP UI) menunjukkan bahwa implementasi risk register belum optimal, ditandai dengan ketidaklengkapan pencatatan risiko, absennya perhitungan tingkat risiko, ketidakjelasan penetapan prioritas, serta tidak adanya dokumentasi hasil monitoring dan evaluasi. Penelitian ini menganalisis implementasi risk register sebagai instrumen pengendali risiko di RSP UI serta peranan faktor individu dan faktor organisasi dalam proses penyusunannya. Penelitian ini menggunakan pendekatan kualitatif dengan desain studi kasus, dilaksanakan pada periode Januari hingga Juni 2026. Informan dipilih secara purposive sampling yang terdiri atas perwakilan direksi, Komite Mutu dan Keselamatan (KMK), pimpinan unit, dan Agent of Change (AoC). Data dikumpulkan melalui wawancara mendalam, observasi lapangan, dan telaah dokumen, serta dianalisis menggunakan triangulasi sumber dan data. Hasil penelitian menunjukkan bahwa pada faktor individu, pengetahuan dan keterampilan teknis, pengalaman kerja, sikap positif terhadap risk register, program edukasi, dan kerja sama tim mendukung pelaksanaan pengelolaan risiko. Namun, pengetahuan konseptual manajemen risiko masih bervariasi antarpelaksana dan implementasi risk register cenderung responsif terhadap monitoring dan pengingat KMK. Pada faktor organisasi, dukungan kepemimpinan, budaya keselamatan yang berkembang, regulasi, pengelolaan sumber daya manusia, serta sistem kerja dan teknologi menjadi faktor pendukung implementasi risk register. Meskipun demikian, masih ditemukan kesenjangan antara regulasi dan praktik di lapangan, belum optimalnya peran SDM KMK dan AoC, serta keterbatasan sistem pemantauan risiko yang masih bergantung pada monitoring manual. Telaah terhadap dokumen risk register menunjukkan bahwa proses identifikasi, analisis, evaluasi, dan perlakuan risiko telah dilaksanakan pada seluruh unit kerja. Namun, dokumentasi risiko belum sepenuhnya komprehensif dan belum seluruhnya selaras dengan komponen proses manajemen risiko yang dijelaskan dalam Keputusan Menteri Kesehatan Republik Indonesia Nomor HK.01.07/MENKES/1354/2024. Penelitian ini menyimpulkan bahwa faktor individu dan faktor organisasi berperan sinergis dalam implementasi risk register sebagai instrumen pengendalian risiko di RSP UI, namun masih diperlukan penguatan pada aspek pengetahuan konseptual manajemen risiko, penyempurnaan regulasi dan panduan teknis, optimalisasi SDM KMK, serta pengembangan sistem pemantauan risiko yang terintegrasi guna meningkatkan keselamatan pasien secara berkelanjutan.

Hospitals face complex and multidimensional risks that can adversely affect patient safety and the quality of care. The risk register is an important risk management instrument that structurally records the processes of risk identification, analysis, evaluation, and treatment. However, findings at Universitas Indonesia Educational Hospital (RSP UI) revealed that the implementation of the risk register remains suboptimal, characterized by incomplete risk documentation, the absence of risk level calculations, unclear priority setting, and a lack of monitoring and evaluation records. This study analyzes the implementation of the risk register as a risk control instrument at RSP UI by examining the role of individual and organizational factors across all stages of its development. This study employed a qualitative approach with a case study design, conducted from January to June 2026. Informants were selected through purposive sampling, comprising representatives from the hospital board of directors, the Quality and Safety Committee (KMK), unit heads, and the Agent of Change (AoC) team. Data were collected through in-depth interviews, field observations, and document review, and analyzed using source and method triangulation. The findings revealed that individual and organizational factors synergistically influenced the implementation of the risk register at RSP UI. Individual factors, including technical knowledge and skills, work experience, positive attitudes toward the risk register, educational programs, and teamwork, supported risk management practices. However, conceptual knowledge of risk management varied among implementers, and risk register activities tended to remain reactive, relying on monitoring and reminders from the KMK. Organizational factors, including leadership support, a developing safety culture, regulations, human resource management, work systems, and technology, also facilitated implementation. Nevertheless, gaps remained between formal regulations and actual practices, particularly regarding the limited human resource capacity of the KMK, suboptimal understanding of AoC roles, and risk monitoring systems that still depended largely on manual processes. Document review showed that risk identification, analysis, evaluation, and treatment had been implemented across all units. However, risk documentation was not yet fully comprehensive and had not entirely aligned with the risk management process components required by the Decree of the Minister of Health of the Republic of Indonesia Number HK.01.07/MENKES/1354/2024. Key findings included incomplete documentation of risk causes and impacts, the absence of residual risk and risk decision records, the lack of an integrated organizational risk map, and inconsistencies in documenting risk treatment strategies. This study concludes that the risk register has functioned as a risk control instrument at RSP UI. However, improvements are still needed in conceptual knowledge of risk management, refinement of regulations and technical guidelines, optimization of KMK human resources, and development of a more integrated risk monitoring system to support effective risk management and continuous improvement of patient safety.