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Muhammadiyah Journal of Nursing

Sri Suparti, Elsye Maria Rosa, Yuni Permatasari I

Universitas Muhammadiyah Yogyakarta suparti2464@yahoo.com


Background: Reporting of patient safety safer, more awareness in implementing patient safety reporting
culture will require knowledge, awareness to change attitudes and behaviors become habits. Efforts to
improve the knowledge, attitudes and behaviors with training demonstrations.

Objective: The level of knowledge, attitudes and behavior as well as provide recommendations to improve
patient safety reporting culture in IBS Klaten RSST.

Methods: action research, with purposive sampling, the population is nurses IBS Klaten, validity
triangulation, with content analysis.

Results: Cycle I know the level of knowledge and ideology. Change of attitude: cognitive, all participants have
no intention to make a report. A ff changes changes changes changes changes changes from from discussion
discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion
discussion discussion discussion discussion discussion discussion discussion discussion discussion discussion
discussion discussion discussion discussion discussion inc inc. Cycle II increased knowledge on the application
and analysis, report formats charging 88.94 value. Change of attitude: cognitive, each participant has the
courage to report the incident and present 1, reporting the presence of behavioral change: of fi ve
incident. Cycle III: The level of knowledge on the application, analysis and synthesis, charging value increased
to 93.09 report format. Attitude: cognitive, a ff ective, conative.According to the intensity at the level of respect
and respondents reported (dare report all incidents). Changes in the number of reports the existence of 17
incidents. (22 reporting in 3 cycles). Data obtained KTD types of incidents: 7, KPC: 8, KNC: 4, and KTC: 3
Conclusion: Action research with three cycles of training demonstrations, an increase in knowledge, change
attitudes and behavior of all participants. There is a plan to follow-up and reporting of patient safety culture
recommendations and unknown risk grading matrixs.

Keywords: Cultural Reporting, Patient Safety, Demonstration Training

Action Research: Patient Safety Incidence Reporting at IBS Dr. Soeradji Tirtonegoro


Hospital patient safety is a system to make patient care safer that include risk
assessment, identification and management of matters relating to the risk of the patient, reporting
and analysis of incidents.Patient safety incidents are any unintentional events and conditions that
result or potentially result in preventable injuries to patients ie KTD, KNC, KTC, KPC. KTD is an
incident that results in injury to the patient. KNC is an incident that has not been exposed to the
patient, KTC is an incident that has been exposed but not injured, KPC is a potential condition of
injury (Permenkes RI No. 1691, 2011).

KTD year 2000 according to research at Utah Hospital and Colorado: 2.9%, who died: 6.6%. In
New York: 3.7%, mortality rate 13.6%. Number of deaths due to KTD / Adverse event of
hospitalization throughout the United States 33.6 million / year: 44.000-98.000 / tahun. WHO in
2004 collected hospital research figures in various countries: America, England, Denmark, and
Australia, found KTD ranges from 3.2 to 16.6%, with the data eventually developing countries
developed a patient safety system (MOH, 2008 ). Reports of patient safety incidents in Indonesia
by Province found 14 out of 145 reported incidents in 55 cases (37.9%) in Jakarta. Based on the
type of 145 reported incidents, KNCs were found: 69 cases (47.6%), KTD: 67 cases (46.2%) and
others: 9 cases (6.2%) (Lumenta, 2008).

Muhammadiyah Journal of Nursing

Seven steps in the patient safety program, step 4: develop a reporting system, make sure your
staff can easily report incidents, as well as hospitals organize reporting to KKP-RS4. Reporting is
the basis for detecting patient safety issues, other sources of information that can be used by
health and national services (WHO, 2005).

IKP reporting is the basis for establishing a safer patient care system; 3 key activities are: 1)
Encourage all staff to report patient safety issues, especially low-level reporting groups. High
levels of reporting usually exist in a safer hospital, 2) Reporting to be channeled to the national
level ie KKPRS for joint learning process, 3) Efforts to reduce incidence severity: risk managers
should see all reports of deaths on KTD before being sent to KKPRS. The head of the hospital
must receive reports and activity plans of all deaths directly related to the IKP (Lumenta, 2008).

Good reporting can improve the quality of patient safety, if well documented, and all implement
a reporting culture every time there is an IKP. Culture is a habit that can be done by someone without
waiting for command, so that culture can be applied well, then one must have knowledge, awareness,
to change attitude and behavior become a habit. Quality is the total picture of the nature of a service
related to its ability to provide satisfaction needs. Quality in hospital services is useful to reduce the
level of disability or error (Wijono, 1999).

Efforts undertaken to cultivate IKP reporting need to improve knowledge, understanding of


reporting for hospital service quality and patient safety, training on the concept of patient safety,
type of incident, how to fill in internal incident reporting format, and reporting flow. The goal is
for the nurse to understand, and know the benefits of reporting in case of KTD / KNC / KTC /
KPC (Ariyani, 2008).

Training is the process of helping others in acquiring skills and knowledge (Marzuki,
1992). Training is the process of giving workers help to master special skills, help

improve its shortcomings in carrying out the work (Notoadmojo, 2003). The demonstration
training method describes and demonstrates through examples, and is very effective, because it
is easier to show how to do a task, because it is combined with learning aids: pictures, material
texts, lectures, discussions (Wibawa, 2007). Methods of demonstration are more effective than
video to improve attitudes and knowledge (Wibawa, 2007).

In RSST Patient Safety team has been established since 2007, then revised the patient safety team
in 2011, there is a program of patient safety team activity but has not been implemented optimally,
especially the reporting documentation. Filling in the internal incident report format has not been
optimally disseminated throughout the service unit, especially in IBS, so the nurses at IBS have not
understood how to report using the format, so far every incident or a few days after the incident, they
reported orally both from the room, medical, nurse supervisor, other employee, or complain from
family. The incident that occurred by the room reported to his superior / head of space, then head
chronology writing space briefly dibuku problem of the room, and proceeded to report to the

Muhammadiyah Journal of Nursing
the patient safety team, then the patient safety team tracked, and clari fi ed the spatial incident
and then made the report using the internal incident format of the hospital and conducted
medical / nursing audit / audit to know the chronology of the incident, then there is discussion
and follow-up in the form of SOP, but have not done RCA (Nursing Service Field, 2013)

Number of incident reporting in 2013:

3. at IBS in January - August 2013:

31 incidents with zero reports. According to interviews from several nurses at RSST there were
several incidents that were not reported, among others: mistaken drugs but known error when
the room service conducted checks and drugs have not been given to patients, patients fall,
misclassified genital identities, wrong side surgery, when delivering the patient will be carried
out supporting action. Not all the nurses have dared report the incident to the patient safety team,
based on interviews to some nurses on the matter because of the fear of blame, lack of
understanding of the benefits of reporting, do not know how to report.

From the preliminary study that the researchers did, the incident reporting data was not optimally
performed by the nurses, so the researcher wanted to do the action research of patient safety reporting
with the method of demonstration training in Dr. Soeradji Titrtonegoro Klaten.


Qualitative research type with Action Research design . Action Research , is the process a three-cycle
spiral consisting of planning, action, observation, and re fl ection10. Each cycle consists of four phases,
phase 1adalah plan, phase 2 Action, observation stage 3, stage 4 Re fl ection.
Figure 3.1. A cycle of action research (adapted from Kemmis & McTaggart.1992)

Table 4.2. Respondent's Characteristics at IBS RSUP Dr. Soeradji Tirtonegoro Klaten Month
September to November 2013

No. Characteristics amount

1 Gender
Man 5
Women 0
Total 5
2 Age
40-50 Years 4
51-60 Years 1
Total 5
3 Level of education
D3 Nursing 4
D4 Nursing 1
Total 5
4 Length of working
20-25 Years 2
26-30 Years 3
Total 5
5 Position
Head of Space 1
Coordinator of Operations Room 4
Total 5

Primary Data Sources, September 2013

Muhammadiyah Journal of Nursing

From table 4.2 above it can be seen that by sex, all participants are male , age mostly 40 to 50
years: 4 people. Education mostly D.III Nursing: 4 people, length of work mostly 26 to 30 years old,
positions of most participants as coordinator: 4 persons.


Cycle I (First) Planning cycle 1, the source is from Muhammadiyah University of Yogyakarta, with
material about root cause of sentinel events, wrong site surgeries, patient patient safety type, patient
safety concept, multi causal theory, incident type, 6 patient safety target, safe surgery, bundles of care
in surgical site infection, the importance of incident reporting, incident organizational
models, identification of risks, blaming. Who is responsible for incident reporting, what should and
should not be reported, case examples. The training model is lectures, discussions and frequently
asked questions. The second informant is the researcher himself with the material on the internal
incident report reporting format in the hospital as well as the flow of reporting in case of patient safety
incidents, lecture method, discussion and demonstration.

Action / Implementation, explanation of training materials in accordance with the planning,

lecture training model, question and answer discussion, demonstration. A 120-minute training
duration, in the RSST Medical and Nursing Board meeting room, on Wednesday 25 September
2013 at 12.30 - 14.30 pm, followed by 5 participants from IBS. Training materials in cycle 1 are
described according to plan.

Monitoring / observation of the training implementation process, conducted by the

researchers along with the provision of training materials, during the training from the beginning
to finish the delivery of the material, all participants were silent because they do not know about
patient safety and how to make a report in case of incidents, while
change her sitting position and take her seriously. From 5 participants, there were 4 participants
who actively asked, and began to understand, seen from the evaluation / observation during the

Reflection / evaluation, after being given training material by the method of the
demonstration, all participants initially did not know about Patient Safety, these types of
incidents, how the reporting formats incident report internal hospital and workflow reporting,
then after training approximately 120 minutes, all participants serious attention, and active

Cycle II (Second), plan redefined related to patient safety incident (KTD, KNC, KTC, KPC),
how to fill internal incident report format. Action / Implementation explains how to fill in internal
incident report format, incident type about KNC, KTC, KTD and KPC.

Each participant describes the results of the internal incident report filling format. Monitoring
/ Observation.

Table. 4.3. Results of Assessment of Internal Incident Format Score at IBS RSUP Dr. Soeradji
Tirtonegoro Klaten On Cycle II Year 2013

No Cycle II amount Score Value

1 Participant I 1 20 82.75
2 Participant II 1 20 89.65
3 Participant III 1 20 96.55
4 Participant IV 1 20 93.00
5 Participant V 1 20 82.75
Average Amount 5 88.94

Based on table 4.3 above can be seen that the results of the report on the results of the
implementation of the incident of patient safety in IBS in the second cycle is each participant
exposes 1 incident with a score of 20, the assessment of the filling format of the highest internal
incident report is the 3rd participant is 96.55.

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Table 4.4. Incident Data at IBS in Cycle II of 2013

No Incident Type amount Ket
1 The Operation Plan was delayed due 1 KPC
blood supply does not exist yet
The operation was postponed
2 because of the patient 1 KPC
hot 39 o C.
3 Operation action canceled due 1 KNC
high tension 200/110 mmhg.
4 Incorrectly wrote an action plan 1 KNC
orif fr operations plan. acetabulum
but written fracture orif Clavicula.
5 Incident includes antibiotics 1 KTC
not in the skin test first
(not according to procedure).
amount 5

Graph. 4.1. Number of Incidents at IBS RSUP Dr. Soeradji Tirtonegoro Klaten On Cycle II
Year 2013

From the result of the assessment of the internal incident report format it is known that the
incident types are: KPC, KTC, and KNC, most of which are KPC and KNC, each 2 incidents.

Discussions Re reflection. After being re-explained about filling in the internal incident
reporting format and the incident type and the incident's presentation, the 5 participants began
to understand how to fill out the report format, but there are still some who have not understood,
namely: the action taken when the original incident happened to another unit, related units, the
perception of incident location (pre, intra and post-operative).

Cycle III (Three). Follow-up plan for all participants to describe the 2nd stage incident. Action
/ implementation of each participant describes the results of the internal incident report
submission format.Monitor / evaluation
by matching the suitability of filling the internal incident report format of each participant to the
standard / technical guidance that has been determined, the scoring results are listed in the
following table:

Table. 4.5. Results of Assessment of Internal Incident Format Score at IBS RSUP Dr. Soeradji
Tirtonegoro Klaten On Cycle III of 2013

No Cycle III amount Score Value

1 Participant I 2 11.76 89.65
2 Participant II 4 23.52 95.17
3 Participant III 5 29.41 94.48
4 Participant IV 2 11.76 94.82
5 Participant V 4 23.52 91.37
Average Amount 17 93.09

Based on table 4.5 above it can be seen that the results of the report implementation scores on
the patient's safety incidents in IBS in this third cycle, the highest results made reporting there
are: 5 incidents reported by participants 3 with score 29.41 with the assessment of internal
incident report format: 94.48, while the highest internal incident report incident rating results
were made by participant 2 with the number of reported incidents 4 with a score of 23.52 and the
total value of the internal incident report format is: 95.17.

Table 4.6. Incident Data at IBS In Cycle III of 2013

No Incident Type amount Ket

1 Blood sampling of PRP is not taxable, 1 KTD
repeated lasi, blood vessels
2 The operation plan is delayed due 1 KNC
high blood (210/120 mmhg)
SPO (Letter of Approval of
3 Operation) 1 KPC
not available
4 Less use of Instruments 1 KPC
5 Patient occurs prolong because 1 KTD
operator is not ready but anesthesia
already done anesthesia

Muhammadiyah Journal of Nursing

No Incident Type amount Ket

6 Saturation down after installation 1 KTD
ET (30)
7 When in RR bleeding and stosel 1 KTD
from the nose about 25 cc.
8 Desaturation to 2 % SPO 0% 1 KTD
for 5 minutes resolved
9 HBSAG (+) is not exchanged 1 KPC
10 The mistake of writing blank 1 KTD
shipping frozen by name
patients, CM and DX medical ones
the same as the first patient.
11 Installing Laringeal Mask Airway 1 KTC
(LMA) more than 1x failed.
12 Patients with HBSAG (+) without 1 KPC
notification to IBS.
13 No sign at location of operation. 1 KPC
14 There was trauma to the intestine 1 KTD
The patient was suspended due to his
15 operation 1 KNC
Low Blood Pressure (TD 80/40
16 Orthopedics can not be installed 1 KTC
17 Patients plan laparotomy surgery 1 KPC
postponed due to experience
saturation decrease up to 45 minutes.
amount 17

Graph. 4.2. Number of Incidents at IBS RSUP Dr. Soeradji Tirtonegoro Klaten On Cycle III of
perform reflection / discussion), in the determination of the type of incident is still being debated
when the participants first presentation of case findings, the participants 5 respond to the
exposure presented by participants 1 related mistakes in writing the name, no RM and diagnoses
on examination format PA.

Evaluate the success of charging observation format for internal incident report for action as
well as the number of events occurring patient safety incidents and the number of reporting made
by the respondent during the three cycles is seen following graph.

Graph. 4. Results of Incident Format Rating During Cycle I, II, III At IBS RSUP Dr. Soeradji
Tirtonegoro Klaten September to November 2013

Based on the number of patient's incident safety reporting reported by 5 participants in cycle
3 there were: 17 incident reports with the most incident type were KTD: 7, KPC: 6.

Reflection on the third cycle, all the participants have started to understand how to fill in the
internal incident format, but to determine the type of incidents are still somewhat confused (as
seen from the fifth participant's facial expression when
From the results of reporting done by the participants during the three cycles of data obtained an
increase in score reporting signi fi cant that is from 0 to 20 and in cycle 3 to 23:52. Increase the
incidence value of internal incident report formats from all participants of the cycle

1: 0, cycle 2: 88.04 and cycle 3: 29.41. Based on the number of incident reporting

patient safety conducted by 5 participants in cycle 1 to 3 is 22 incident report with the most
incident type is KPC: 8, KTD: 7, while the incident is most encountered in the phase of Intra
operation that is there are 14 of 22 incidents, be it KTD, KNC, KTC and KPC. as in the graph below

Muhammadiyah Journal of Nursing


Table. 4.7. Incident Data at Cycle I, II, III at IBS RSUP Dr. Soeradji Tirtonegoro Klaten
September to November 2013

No Incident Type amount Ket

The patient was suspended due to
18 his operation 1 KNC
Low TD (TD 80/40 mmhg)
19 Patients plan laparotomy surgery 1 KPC
postponed due to experience

saturation decrease up to 45

No Incident Type amount Ket

1 The operation plan is delayed due 1 KPC
blood supply does not exist /
not taken yet
The operation was postponed
2 because of the patient 1 KPC
hot 39.8C
The operation plan was delayed
3 due 1 KNC
high blood pressure (210/120
4 Patients with HBSAG (+) 1 KPC
without notice to IBS
5 Incorrectly wrote an action plan 1 KNC
operating plan ORIF Clavicula,
but his patient fr. acetabulum
SPO (Letter of Approval of
6 Operation) 1 KPC
not available
7 No marks on location 1 KPC
8 Incident includes antibiotics 1 KTC
not in the skin test first
by the circulation team (not
9 Blood Collection PRP (Platclct 1 KTD
Rich Plasma) does not hit / recur
times, broken blood vessels occur
10 The use of that instrument 1 KPC
11 Operation action canceled 1 KNC
because of the high tension of
200/110 mmhg,
after mounting the monitor

20 Installing Laringeal Mask 1 KTC

Airway (LMA)> 1x failed
21 Orthopedics can not 1 KTC
installed DC
22 When in RR bleeding and stosel 1 KTD *
from the nose about 25 cc
amount 22

Primary Data Sources: IBS Nurse Reporting * Signs are performed by the Patient medical
audit Safety RS
Graph. 4.4. Number of Incidence Types At Cycle I, II, III at IBS RSUP Dr. Soeradji Tirtonegoro
Klaten September to November 2013.

12 Patient occurs prolong because 1 KTD

operator is not ready but anesthesia
already done anesthesia
13 Saturation down after installation 1 KTD
ET (30)
14 Desaturation occurs, SPO2 becomes 1 KTD *
15 HBSAG (+) is not exchanged, 1 KPC
known after entering in OK VII
16 Error writing blank 1 KTD
shipping frozen (patient name,
CM, medical diagnosis) are the same
with the first patient
17 There was trauma to the intestine 1 KTD *
Graph. 4.5. Number of Incidence Types at Three Cycles at IBS Soeradji Tirtonegoro Klaten
September to November 2013.

Muhammadiyah Journal of Nursing

After Action Research three cycles of interviews with the head of space and the head of the
patient safety team.
Figure 4.6 Results of In-depth Interviews on Culture of Patient Safety Reporting with IBS
Headroom and Head of Patient Safety Dr. Soeradji Tirtonegoro Klaten

After 3 cycles of training to 5 participants, by looking at the improvement of knowledge,
attitude and behavior change, can be seen in the following discussion:

1. Increased knowledge of Cycle I, Participant 1 new at Knowledge Level, 2, 3, 4, 5 participants

have increased knowledge at comprehension level, participant 3, knowledge enhancement at
comprehension level.Cycle

II: Participant 1 at the level of Using / application, participants 2, 3, 4, and 5 at the level
Describe the analysis of incident reporting incidents of participants 1: 82.75 Entering good
category, participants 2: 89,65 In good category, participants 3: 96,55.

entering good category, participants 4: 93,00. entering good category, participant 5: 82,75. good
category. Cycle III, participant 1, at the Apply / aplication level, participants 2 and 5 are at the infer /
synthesis level, participants 3 and 4, able to describe / analyze. Assessment of participant incident
reporting format 1: 88,65. entering good category, participants 2: 95,17. entering good category,
participants 3: 94,48. entering good category, participants 4: 94,82. entering good category, participant
5: 91,37. good category. Ariyani (2009), on the analysis of knowledge and motivation of nurses that
influence the attitude of supporting the application of patient safety program Supporting attitude is
high (76,3%), good nurse knowledge (76,3%) good nurse motivation (7,1%). Authority (2007), in
a bag fi Effectively Difference Method with Video Playback Demonstration against Improved
Knowledge, results showed no difference between the method of demonstration and video methods
in improving the knowledge demonstrated increased knowledge 58.97% higher in the treatment
group demonstration (authority, 2007). In the case of research conducted by the researcher,
participants after being trained using demonstration method with action research, on 3 cycles
experienced knowledge improvement, 1 participants at the application level, 2 participants at the
analytical level, and 2 participants at the synthesis level. Assessment of knowledge level is seen in the
results of internal incident reports, all the values of 5 participants are categorized well, cycle 1: 0, cycle
II: 88.94 and cycle III: 93.09. So in this study increased knowledge of the significant participants in
making use of an internal incident report format hospitals, from 0 to 93.09. According to the Human
Cognitive Bloom there are 6 levels: knowledge,

Muhammadiyah Journal of Nursing
comprehension, application, analythical, synthesis level, valuation. In accordance with this
research that after the training on 5 participants, each participant increased knowledge at the
level of application until the synthesis, the results of this study with the opinions of
researchers and references that researchers get almost the same, that research demonstration
is very influential to increase knowledge good views from the level or assessment of the
internal incident report format conducted by all participants.

2. Attitude changes in cycle I. Cognitive: all participants have the intention to make reporting,
affective views of discussion / re fl ection, in the discussion has begun to understand the type of
incident and how to create reports using internal incident report format. Cycle II, Cognitive: all
participants have dared to report incidents each reported 1 incident and presented. In discussions
re fl ection discussed each other about the type of incident, the location of the event that according
to the participant it is convinced the idea . Conviction has a tendency to behave to make an incident
report that occurred in the operating room. Viewed from the level of attitudes, participants 1, at the
responding level, participants 3, and 4, his attitude was at the level of responding, participants 2
and 5 have reached the level of respect. Cycle III, cognitive attitude, all participants have dared to
report incidents from each participant participant 1: 2, participants 2: 4, participants 3: 5,
participants 4: 2 and participants 5: 4 incidents. In this cycle 3 the attitude changes of the
participants according to their intensity at the level of respect and responsibility. In accordance
James A (2004), in his research, Nurse signi fi cantly reported> 80% from medical error. Unreported
reasons include a lack of certainty about what

which is considered an error in the table

3 (40.7%) and concerns about others have implications (37%). Interventions that will lead to
increased reporting include education on errors that should be reported in table 4 (65.4%), regular
feedback on reported error (63.8%) and on individual events (51.2%), evidence of system changes due
to error report (55.4%), and electronic format for report (44.9%). José D Jansma (2011), in his 2 x results
training: 25 people (57%) experienced a positive change in knowledge, skills and attitudes found after
the training. Patient safety training has a long-term positive effect on knowledge, skills and attitudes,
and influences respondent reporting behavior. According to Robbins (2001) there are three
components of the structure of attitudes that are important and mutually supportive components:
cognitive, affective, konatif. Attitudes have levels based on their intensity: receiving,
responding. Appreciate (Robins, 2001). Almost the same as the results of this study, that with training
it can change the attitude of all participants, who initially before the training all participants are afraid
to report, fear of blame, do not know how to report, do not know the benefits of incident reporting,
after three cycles from September 25 to November 15, 2013, all participants have dared to report
incidents that occurred in the IBS of 22 incidents. In accordance with this study for attitude changes
seen from the intensity that all respondents have changed attitude seen from cognitive, affective and
intensity. Participants

1 at the responding level, participants 2 and 5 at the level of respect, participants 3 and 4,
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at the responding level.

3. Changes in behavior. In cycle I, there was no change of behavior, before the training there
were 31 incidents with zero reporting. Cycle II, changes in behavior of each participant reported 1
incident, total reporting was 5 incidents. Seen from predisposing, enabling and strengthening
factors to 5 participants. Cycle III Behavior change, all participants already have the awareness to
report any incidents, on 3: 17 incident reports, total reporting over 3 cycles: 22 reports of 22 incidents
by 5 participants, this has proven that after the action training with demonstration methods was
already there improvement / behavior change. Judging from the predisposing, enabling and
strengthening factors, very good influence of training on behavior change of participants in this
research. Predisposing factors are the respondent's confidence to make reporting, the enabler factor
that respondents do incident reporting by using the internal incident format that has been
provided, the reinforcing factor that all respondents have made reporting every incident according
to the rule that is using report format and reported within 2x24 hours accordingly with existing
rules in RSST. Behavior change in all participants after training using the demonstrated
demonstration method has undergone a better change, initially prior to training, there is no
participant behavior to report any incidents, but after training there has been a remarkable increase
from 0 to 22 reporting over three cycles. Training will increase knowledge, attitude and behavior
so that there will be improvement of patient safety reporting culture,

in accordance with the opinion of the researchers and theories, with action research with three
cycles gained increased knowledge, attitude change and behavior and based on the results of
interviews with the head of the room and patient safety team leader that the patient safety
reporting culture needs training, . In accordance Fadi El-Jardali study (2011), Advest Event
Reporting, communication, leadership and management of patient safety, staff, and
accreditation be identified as a major predictor of patient safety culture. Natasha J Verbakel (2013),
with a random cluster, with 3 control trial trials, conducted in 30 general practices in the
Netherlands. Results include the number of reported incidents and indicators of some quality and
safety culture of the patient. as well as interviews conducted follow-up to evaluate the process of
implementation of the intervention. The results of this study will provide insight into the effects
of providing a cultural questionnaire or questionnaire with complementary workshops.
4. In this study, participants were researchers conscientious nurses, for nurses who tend to
contribute more aware of the event / incident in the operating room, so that nurses tend to
contribute to greater reporting of incidents, regarding to researcher James A (2004),
Nurse significant report> 80% of MR, Reason not reported pd tb 3 (40,7% R), worry about other
people have implication (37%). Interventions that lead to increased reporting / education
concerning errors should be reported on tb 4 (65.4% R). In order for participants to know and will
change attitudes and behaviors, it is necessary to conduct training on patient safety, such as
researcher José D Jansma (2011), the training greatly influences knowledge, skills and

Muhammadiyah Journal of Nursing

sikap seseorang untuk penanganan insiden Patient Safety, trampil untuk memperhatikan dan
menganalisa insiden, mampu menilai jenis insiden yg layak dilaporkan, menyadari
pentingnya pelaporan insiden & memiliki niat untuk melaporkan, memiliki efek positif pada
pelaporan insiden. Pelatihan Patient Safety memiliki efek positif jangka panjang pada
pengetahuan, ketrampilan dan sikap, dan mempengaruhi perilaku pelapaporan.

5. Persamaan dengan penelitian ini setelah dilakukan pelatihan tiga siklus juga dilakukan
wawancara dengan kepala ruang maupun tim patient safety untuk rencana tindak lanjut dan
rekomendasi terhadap manajmen/

pimpinan rumah sakit untuk optimalisasi budaya pelaporan patient safety. kalau dibandingkan
denga peneliti sebelumnya yaitu Joel S, (2008), wawancara dilakukan oleh dokter secara langsung dan
parallel kepada pasien sehinggadidapatkan hasil: Dari 998 studi pasien, 23% memiliki 1 adverse
events terdeteksi oleh wawancara dan 11% memiliki 1 adverse events yang teridenti fi kasi oleh
medical record. Grading, berdasarkan hasil penelitian dengan action research, didapatkan jenis
insiden KTD yang tidak terjadi cedera ada: 3, mengalami cedera ringan ada: 2, dan cedera sedang ada:
2. Berikut hasil grading matrixnya dilihat pada setiap insiden KTD.

Frekwensi Impact Potensial Konsekwensi Action

Sangat sering terjadi Tidak cedera Moderat (risiko sedang) 1. Dilakuan investigasi sederhana
(Tiap mgg/bln) 2x sebulan signi fi kan) 1. Salah menulis blangko paling lama 2 minggu.
pemeriksaan PA 2. Manajer/pimpinan klinis menilai
Pendarahan di RR, dampak terhadap biaya dan
2. setelah kelola
post operasi risiko.
3. Saturasi turun setelah
pasang ET
Sangat sering terjadi Cedera ringan Moderat (risiko sedang) 1. Dilakukan investigasi sederhana
(Tiap mgg/bln) 2x sebulan (Minor) 1. Pengambilan darah PRP paling lama 2 minggu.
> 1 kali, pembuluh darah 2. Manajer/pimpinan klinis menilai
dampak terhadap biaya dan
pecah kelola
2. Disaturasi risiko.
Sangat sering terjadi Cedera sedang High (risiko tinggi) 1. Dilakukan RCA paling lama 45
(Tiap mgg/bln) 2x sebulan (Moderat) 1. Trauma usus duodenum hari.
2. Prolong karena operator 2. Kaji dengan detail dan perlu
masih mengerjakan
pasien tindakan segera.
lain, pasien sudah dibius 3. Membutuhkan perhatian top

Gambar 4.8. Risk Grading Matrix pada setiap Insiden dan Tindakan yang dilakukan

Pada gambar diatas dapat dilihat grading maupun tindakan yang seharusnya dilakukan oleh
tim patient safety, Grading dilaksanakan pada awal sebelum terjadi KTD, sehingga tahu apa yang
akan dilakukan oleh rumah sakit. Dari 7 insiden tersebut, yang masuk dalam potesial
konsekuensi moderat adalah 5 insiden, dan yang masuk dalam potesial konsekuensi high risk
ada 2 insiden. Tindakan pada high risiko dilakukan tindakan pembahasan kasus dengan RCA
dalam waktu 45 hari dan di lakukan identi fi kasi secara
mendetail serta perlu untuk segera ada tindakan dari top manajer.

Kekuatan dan Kelemahan Penelitian

1. Kekuatan

a. Sudah adanya program dari Tim Pasien safety.

b. Metode action research sehingga insiden yang selama ini tidak terlaporkan bisa
digali permasalahannya/alasannya

Muhammadiyah Journal of Nursing

c. Sampelnya dengan menggunakan perawat coordinator kamar operasi dan

penanggung jawab IBS sudah sesuai

d. Instrumen pelaporan insiden internal rumah sakit sesuai standar Depkes

e. Materi pelatihan yang digunakan sudah baku.

2. Weakness

a. Metode penelitian action research harus dilakukan beberapa kali tindakan

sehingga membutuhkan kejelian.

b. Sampelnya 5 responden sehingga tidak bisa digereralisir untuk satu rumah sakit,
hanya sesuai untuk IBS saja.

c. Ujivaliditas transferbility tidak bisa digunakan untuk ruang lain selain IBS.

d. Instrumen untuk wawancara belum standard karena berdasarkan hasil dari

penilaian action research (siklus I,II,III).

Berdasarkan hasil penelitian dengan action research dengan tiga siklus serta pembahasan
maka bisa diambil kesimpulan sebagai berikut:

1. Penilaian grading risiko pada jenis insiden KTD yang tidak ada cedera dan yang cedera
ringan, pada matrik grading risiko moderat/ warna hijau, dengan risiko sedang, dilakukan
investigasi sederhana. KTD dengan cedera sedang, matrik grading risiko masuk moderat/
warna kuning, risiko tinggi, dilakukan RCA paling lama 45 hari, kaji dengan detail dan perlu
tindakan segera serta membutuhkan perhatian top manajer

2. Pengetahuan partisipan meningkat dari siklus I sampai dengan siklus III.

a. Pada siklus I terjadi peningkatan pengetahuan pada Knowledge level and

comprehension level.

b. Siklus II terjadi peningkatan pengetahuan pada application and Analysi Level.

c. Siklus III terjadi peningkatan pengetahuan Analysis and Syntesis level.

d. Penilaian Format laporan insiden internal mengalami peningkatan, dari siklus I:

0, siklus II: 88,94 dan siklus III: 93,09.

3. Perubahan Sikap pada Siklus I sampai siklus


a. Siklus I: perubahan sikap kognitif ada niat untuk membuat pelaporan insiden.
Perubahan afektif mulai faham tentang jenis insiden dan cara membuat laporan
menggunakan format laporan insiden internal.

b. Siklus II, sikap kognitif, semua partisipan sudah berani melaporkan insiden pasien
safety dari 0 menjadi 5 laporan. Sikap Afektif semua partisipan memahami jenis insiden,
lokasi. Konatif mempunyai kecenderungan berperilaku untuk membuat laporan insiden.
Dilihat dari tingkatan sikap: pada tingkat menanggapi, dan menghargai.

c. Siklus III sudah berani melaporkan insiden pasien safety sebanyak 17 pelaporan.
Tingkat perubahan sikap pada tingkat Konatif yaitu cenderung berperilaku untuk melaporkan
insiden sesuai sikap yang dimiliki oleh partisipan yang berkaitan dengan adanya insiden di
IBS. Sikap dilihat dari intensitasnya pada tingkat menghargai dan bertanggungjawab untuk
berani melaporkan semua insiden untuk pembenahan sistem di kamar operasi.
4. Perubahan perilaku dengan adanya kesadaran melakukan pelaporan selama tiga siklus
ada 22 pelaporan dari 22 insiden. Perubahan perilaku baik dilihat dari faktor predisposisi
yaitu adanya kepercayaan responden untuk melaporkan insiden, pemungkin yaitu
responden melakukan pelaporan insiden dengan menggunakan format insiden internal yang
telah disediakan, penguat yaitu adanya pelaporan yang dilakukan oleh partisipan sesuai
dengan aturan yang ada di RSST tersebut.

Muhammadiyah Journal of Nursing

5. Adanya rencana tindak lanjut dan optimalisasi pelaporan insiden patient safety:
sosialisasi, motivasi, observasi secara periodic, bimbingan untuk menindaklanjuti,

pelatihan,demonstrasi, revisi protap, pembakuan adanya sign in, Time out, dan sign out, SK
tim investigasi, investigasi dan Grading, dokumentasi, RCA.

6. Ada rekomendasi dari ketua tim patient safety kepada manajemen: inhouse training,
demonstrasi dengan meniru, optimalisasi pelaporan yang baik sistematis dan ada peran

7. Didapatkan data insiden sebanyak 22 insiden, dan jenis insidennya KTD: 7, KPC: 8, KNC:
4, dan KTC: 3


1. Merealisasi Program Tim Patient Safety secara optimal dan kejadian-kejadian yang
mengakomodasi semua unit di rumah sakit.

2. Perlunya dilakukan inhouse training di RSUP Dr. Soeradji Tirtonegoro Klaten untuk
peningkatan pengetahuan dengan metode pelatihan demonstrasi.

3. Perlunya Recording, reporting, pendokumen-tasian, setiap ada Insiden Patient Safety.

4. Perlunya semua perawat memahami tentang jenis Insiden Patient Safety dan cara
pencegahan Insiden Patient Safety.
5. Perlunya sosialisasi dan motivasi serta pemberian reward dalam implementasi
pembuatan laporan.

6. Ada evaluasi pencatatan dan observasi secara periodik terhadap Insiden Patient Safety.

7. Perlunya Pembakuan/adanya SOP tentang pelaksanaan sign in, Time out, dan sign out di
IBS oleh manajemen rumah sakit.

8. Perlunya ada SK Tim Investigasi Patient Safety.

9. Perlunya Tim Patient Safety melakukan Investigasi dan Grading serta RCA setiap ada
Insiden Patient Safety yang berat dan tindak


10. Perlunya revisi protap terkait dengan pelayanan, fasilitas dan sarana prasarana.

11. Perlunya Tim Patient Safety melakukan evaluasi pelaporan Insiden Patient Safety untuk
semua pemberi pelayanan.

12. Untuk peneliti selanjutnya perlu dilakukan penilaian kepatuhan melaksanakan safe
surgery ceklist secara rutin.

13. Perlu dilakukan investigasi yang mendalam dan melakukan RCA untuk kasus High


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