Untuk menjaga dan meningkatkan mutu proses pembelajaran secara kontinyu, diperlukan upaya pemantauan dan penilaian mutu melalui pemantauan kejadian disquality, antara lain pemantauan adverse event (kejadian merugikan). Data tentang kejadian merugikan di negara-negara luar (Amerika, Inggris, Australia) menunjukkan angka kejadian merugikan di sarana pelayanan bervariasi antara 0,006% s/d 36%. Di Indonesia, belum pernah diadakan penelitian tentang kejadian merugikan di pelayanan kesehatan, demikian pula di lingkungan pendidikan kesehatan yang dikhawatirkan potensial terdapat kejadian merugikan dalam pelaksanaan proses pembelajarannya. PeneIitian ini bertujuan untuk menggali konsep kejadian merugikan dalam proses pembelajaran di institusi pendidikan DIII Keperawatan Depkes, dilaksanakan di tiga institusi pendidikan Depkes (Akper Depkes Kimia Jakarta, Akper Depkes Bogor, dan PAM Keperawatan Depkes Jambi). Metoda penelitian yang digunakan adalah kualitatif yang bersifat eksploratif. Data diperoleh melalui diskusi kelompok terarah dengan mahasiswa, wawancara mendalam terhadap direktur, dosen dan praktisi pendidikan, dan telaah dokumen. Hasil penelitian menunjukkan, kejadian merugikan yang dialami mahasiswa di kelas berkaitan dengan ketidaksesuaian jadwal tatap muka, strategi mengajar kurang tepat, kekurangan fasilitas/sarana, hubungan interpersonal dosen mahasiswa kurang akrab, perbedaan pendapat di antara dosen, dan libur yang dirasakan kurang. Sedangkan kejadian merugikan di lahan praktek berkaitan dengan kurangnya kesempatan praktek dan kurangnya bimbingan dari dosen/instruktur klinik. Dampak bagi mahasiswa berupa kerugian waktu, kurangnya konsentrasi belajar, kurang memahami materi yang diberikan, kurang pengetahuan, bingung mana materi yang benar, kelelahan dan kejenuhan, kurang motivasi belajar/praktek, kurang terampil, kurang percaya diri, mahasiswa menjadi pasif, kerugian nilai dan tidak lulus. Penyebab kejadian merugikan yang ditemukan meliputi penyebab yang sifatnya institusional (keterbatasan tenaga, fasilitas/sarana, biaya, perencanaan dan pengorganisasian yang kurang tepat), dan penyebab yang sifatnya individual (kelalaian dosen/instruktur klinik mengikuti jadwal atau ketentuan yang ditetapkan, sikap dosen, dan kemampuan dosen yang menyangkut kompetensi mengajar). Untuk meningkatkan mutu pelaksanaan proses pembelajaran bagi dosen/instruktur klinik diharapkan tetap menyiapkan rancangan pengajaran, meningkatkan wawasan, dan menghargai mahasiswa sebagai mitra. Bagi institusi pendidikan diperlukan pemantapan pengorganisasian, perencanaan, pemenuhan kebutuhan sumber daya, melibatkan staf dan mahasiswa/masyarakat dalam mengatasi masalah, menanamkan tanggung jawab pada staf/membina kerjasama, menetapkan standar kerja operasional secara eksplisit, dan melaksanakan pemantauan dan penilaian mutu melalui survey atau penelitian. Bagi Pusdiknakes/Depkes diharapkan tetap memantau pelaksanaan program pembelajaran, menggerakkan institusi pendidikan untuk menyusun standar kerja operasional, memperketat seleksi institusi yang akan menyelenggarakan program tambahan, meningkatkan bantuan fasilitas dan sarana, dan memberikan otonomi yang lebih luas pada institusi dalam hal pendanaan.

To assure and to improve quality of learning process continuously, it is needed to monitor and evaluate the quality by monitoring dis-quality events. This is called adverse event monitoring. In several countries (USA, UK, Australia), incidence of adverse event in health care is around 0,006% - 36%. In Indonesia, there is no study of adverse event in health care, including in Diploma III Nursing Educational Institution like Academy of Nursing. There is some evidences that adverse event potentially occure on learning process in Academy of Nursing. This is a qualitative study to explore the concept of adverse event on learning process in 3 Academics of Nursing (Jakarta, Bogor, and Jambi). Data gathered by focus group discussion with students, In-depth interview to directors, teaching staff, and educational instructors/facilitators in each institution and review documented data. The result of the study showed that adverse event concept on learning process in Diploma III Nursing Educational Institution is interpreted as a matter of uncomfortable, disturbing, or decreasing student's concentration which resulted in temporary or permanent disability on absorbing the lesson during the learning process. These are related to mis-management of learning at the institutions. The study revealed that adverse events on learning process were associated with inappropriateness schedule of session, inadequate teaching strategic, lack of resources and facilities, poor interpersonal relationship between student and lecturer, different opinion among the lecturer that lead confusion to the students, and inconsistent/unscheduled academic recess. All of adverse events gave rise disability such as unproductive, poor concentration, lack of understanding, lack of student learning, confusion, weary and tiredness, decreased motivation of [earning or practice, lack of skills on nursing, passivity, and low academic performance. These adverse events are related or caused by institutional factors such as lack of resources, inappropriate organizing or planning, and individual. factors such as negligence, inappropriate attitude, and poor competence of lecturer or instructors. The result could be considered as an input for quality monitoring. Sfecifically for lecturer or clinical instructor, it is reccommended to prepare the instructional design continuously, to improve their competence and ability, and involve student in solving [earning process problem. Furthermore, for academic institutions, it is needed to improve their learning process management from planning, organizing, and evaluating; to fulfill resources needed for the learning process; to involve staff and students and or community in solving learning process problems; to provide standard operating procedures clearly for each staff; and to apply quality monitoring process. Further, this study suggests to the Center for Health Personnel and Education Departement of Health to consistently monitor academic process, to stimulate institutions in developing quality standards, to improve selection process for additional academic program, to provide resources for academy, and to establish greater autonomy for academy in financing the institution.