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Patient safety in hospitals is still a crucial issue worldwide, because hospitals are service institutions that seek to cure patients. So patient safety becomes a necessity, it is hoped that there will be no patient safety incidents (zero incidents). One way to control the increasing number of incidents in hospitals is to utilize a reporting system. This study discusses the description of patient safety incident reporting in hospitals in Indonesia and the factors that influence it, in terms of individual, organizational, and government factors. The purpose of this study was to obtain information about the factors that influence the reporting of patient safety incidents in hospitals in Indonesia. This study uses a literature review method with the Garuda Ministry of Education and Culture database, Rama Kemendikbud, Directory of Open Acces Journals (DOAJ), UI Library, Science Direct, PubMed, ProQuest, and Scopus. The results showed that hospitals in Indonesia already have regulations governing patient safety incident reporting. The reporting system used is still manual-based, and reporting practices cannot be said to be successful because there is still a punitive culture, guarantees for the confidentiality of whistleblowers are still in doubt, reporting is not timely, and feedback is still minimal. From the results of the study, it was also found that the factors that can affect the reporting of patient safety incidents in hospitals are individual factors (knowledge, fear, workload, and motivation), organizational factors (feedback, reporting systems, confidentiality, socialization and training, and safety culture), and government factors in terms of policy
Patient safety still is a global issue throughout the world with the high incidence ofhospital patient safety. One way to control patient safety incident rate is through thedevelopment of a reporting system. This study discusses the description of the reportingof hospital patient safety incidents in Indonesia with a literature review design. This studyaimed to get an information about the description of hospital patient safety incidentreports reviewed in Indonesia in terms of the availability of policies and methods usedalso the factors that hinder the reporting of patient safety incidents. This study uses aliterature review design with a database of PubMed, Science Direct, CINAHL, GoogleScholar and Garuda Research and Technology. The search results show that mosthospitals in Indonesia already have a patient safety incident reporting policy and use theoffline reporting method with a form. Broadly speaking, the hospital's IKP reportingprocedures are in accordance with the National Patient Safety Guidelines. But in practicethere are still many that are not in accordance with the reporting flow that should be andstill encounter many obstacles, such as fear of reporting, lack of socialization, lack ofknowledge and motivation, complicated reporting systems, low patient safety culture, noreward, and feedback which is not optimal yet. Results showed, it was found that theoutput from incident reporting such as timeliness and completeness are not yet fullyachieved.Key words:Patient safety incident report, hospital, Indonesia, literature review.
Kata Kunci : Pelaporan insiden, pengalaman kerja, jam kerja, setifikasi pelatihan, pengetahuan, kepemimpinan transformasional, Budaya keselamatan pasien
ABSTRAK Nama : Andre Saphir Trisnadi Program Studi : Kajian Administrasi Rumah Sakit Judul : Analisis Penyebab Terjadinya Medication Error Di Unit Rawat Inap RS Pluit Periode Tahun 2017 – 2018 Pembimbing : Vetty Yulianty Permanasari SSi, MPH Latar Belakang : Keselamatan pasien merupakan dasar dalam pelayanan kesehatan di rumah sakit. Rumah sakit dituntut tidak boleh terjadi kesalahan terutama dalam keselamatan pasien yang berhubungan dengan obat, ini merupakan hal yang penting dan harus dikerjakan sesuai dengan prosedur yang berlaku supaya tidak terjadi medication error. Berdasarkan laporan Insiden Keselamatan Pasien tahun 2017 – 2018, didapatkan peningkatan kejadian medication error sebanyak 5 kasus yaitu dari 16 kasus (2017) menjadi 21 kasus (2018). Tentunya peningkatan ini berpengaruh pada keselamatan pasien dan mutu pelayanan, sehingga perlu dilakukan analisis faktor- faktor penyebab terjadinya medication error tersebut supaya tidak terulang lagi.Tujuan : Mengetahui penyebab dan akar masalah pada peningkatan medication error di Unit rawa Inap RS Pluit 2018.Menganalisis faktor- faktor penyebab medication error pada fase prescribing, fase transcribing, fase dispensing dan fase administrationdi unit rawat inap RS Pluit. Metode :Desain penelitian ini merupakan penelitian kualitatifdengan pendekatan eksploratif. Dilakukan pada bulan mei – juni 2019 di Unit rawat inap RS Pluit. Data primer didapatkan dari wawancara menggunakan pedoman wawancara kepada manajemen rumah sakit dan pihak yang terlibat dari awal pembuatan resep sampai obat tersebut diberikan ke pasien. Data primer juga didapatkan dengan cara observasi langsung di farmasi unit rawat inap dan ruang perawatan. Data Sekunder didapatkan dari telaah dokumen dengan menggunakan formulir Check Listdi unit farmasi rawat inap ataupun Subkomite Keselamatan Pasien RS Pluit. Semua data tersebut akan dilakukan triangulasi sehingga didapatkan hasil yang akurat. Hasil: Medication error ditemukan pada keempat fase ( fase prescribing, fase transcribing, fase dispensing dan fase administration) paling banyak pada fase prescribing karena human errordan peresepan manual bukan karena kesalahan regulasi yang sudah berjalan. Kesimpulan : Perlu dipertimbangkan adanya perubahan dari sistem peresepan manual ke elektronik. Perlu lebih sering dilakukan sosialisasi tentang budaya kesela matan pasien, komunikasi yang efektif dan regulasi yang berhubungan dengan farmasi. Kata Kunci : Medication error, Keselamatan Pasien, Sistem Pelaporan Insiden, Peresepan elektronik, Rawat inap
ABSTRACT Name : Andre Saphir Trisnadi Program Study : Master Administration Hospital Title : Analysis of the causes of medication errors in the inpatient unit of Pluit hospital for the period 2017 – 2018 Counsellor : Vetty Yulianty Permanasari SSi, MPH Background: Patient safety is the basis for health services in hospitals. The hospital isdemanded that there should not be an error, especially in patient safety related tomedicine, this is an important matter and must be done according to the procedure so there is no medication error. Based on the Patient Safety Incident report for 2017 - 2018,there was an increase in the incidence of medication errors in 5 cases, from 16 cases(2017) to 21 cases (2018). Of course this increase has an effect on patient safety andservice quality, so it is necessary to analyze the factors that cause the medication errorso that it does not happen again. Objective: To find out the cause and root of the problem in increasing medication error in the inpatient unit of Pluit Hospital 2018. Analyzing the factors that cause medication error in the prescribing phase, phasetranscribing, phase dispensing and phase administration in the inpatient unit of PluitHospital. Method: The design of this study is qualitative research with an explorative approach.Done in May - June 2019 in the inpatient unit of Pluit Hospital. Primary data was obtainedfrom interviews using interview guidelines to hospital management and the parties involved from the beginning of the prescription until the medicine is given to patients. Primary datais also obtained by direct observation in the inpatient pharmacy unit and the inpatient unit. Secondary data is obtained from document studies using the check list form in the inpatientpharmacy units or the Patient Safety Subcommittee of Pluit Hospital. All data will betriangulated so that accurate results are obtained. Results: Medication errors were found in all four phases (prescribing phase, phase transcribing, phase dispensing and administrationphase) at most during the prescribing phase because of human error and manual prescribingwere not due to regulatory errors that were already running. Conclusion: It is necessary toconsider changes from the manual prescribing system to e-prescribing. Socialization ofpatient safety culture, effective communication and regulations related to pharmacy needsto be more frequent. Keywords : Medication errors, Patient safety, Incident reporting system, Electronic Prescription,The Inpatient Unit