Analisis determinan dan implementasi budaya pelaporan insiden keselamatan pasien di fasilitas pelayanan kesehatan: Sebuah studi literatur
DOI: https://doi.org/10.33024/hjk.v20i7.3627
Barriers to Reporting Incident Reporting Patient Safety Patient Safety Culture
Abstract
Background: Patient safety incident reporting is a critical component of hospital safety systems, yet its implementation continues to face complex barriers. Low incident reporting rates are consistently documented across various healthcare settings globally.
Purpose: To analyze the factors related to and the implementation of a patient safety incident reporting culture in hospitals, based on a literature review.
Method: This literature review was conducted by searching PubMed, Google Scholar, and ScienceDirect databases using the keywords 'patient safety culture,' 'patient safety incident reporting,' 'barriers to incident reporting,' and 'non-punitive response,' covering publications from 2020 to 2025. Fifteen articles were selected based on predetermined inclusion and exclusion criteria.
Results: Determinant factors influencing the implementation of a patient safety incident reporting culture include: leadership and management support, teamwork, open communication, staffing adequacy, non-blame response, and feedback systems. The primary barriers identified were blame culture, fear of sanctions, lack of knowledge about reporting procedures, and minimal feedback on submitted reports.
Conclusion: The implementation of a culture of patient safety incident reporting remains suboptimal. A multifactorial approach encompassing strengthened leadership, just culture, and continuous training systems is required to improve incident reporting rates.
Keywords: Barriers to Reporting; Incident Reporting; Patient Safety; Patient Safety Culture.
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References
Adomah-Afari, A., & Kwaffo, M. (2025). Relationship between organisational factors and compliance with patient safety incidents reporting at two specialist hospitals, Ghana. International Journal of Health Governance, 30(4), 386–396.
Adriansyah, A. A., Setianto, B., Sa’adah, N., Lestari, I., Nashifah, N. S. A., Anggarwati, F. R., & Arindis, P. A. M. (2022). Analisis insiden keselamatan pasien berdasarkan kualitas teamwork dan coordination manajemen Rumah Sakit Islam Ahmad Yani Surabaya. Jurnal Ilmu Kesehatan Masyarakat, 18(3), 135-142.
Alshyyab, M. A., Albsoul, R. A., Kinnear, F. B., Saadeh, R. A., Alkhaldi, S. M., Borkoles, E., & Fitzgerald, G. (2023). Assessment of patient safety culture in two emergency departments in Australia: a cross sectional study. The TQM Journal, 35(2), 540-553.
Alsobou, N., Rayan, A. H., Baqeas, M. H., ALBashtawy, M. S. D., Oweidat, I. A., Al-Mugheed, K., & Abdelaliem, S. M. F. (2025). The relationship between patient safety culture and attitudes toward incident reporting among registered nurses. BMC Health Services Research, 25(1), 612.
Hanafi, A. Z. P. D. (2020). Analisis Implementasi Sasaran Keselamatan Pasien Di Rumah Sakit Umum Daerah Kota Makassar Tahun 2020 (Doctoral dissertation, Universitas Hasanuddin).
Harsul, W., Irwan, A. M., & Sjattar, E. L. (2020). The relationship between nurse self-efficacy and the culture of patient safety incident reporting in a district general hospital, Indonesia. Clinical Epidemiology and Global Health, 8(2), 477-481.
Howell, A. M., Burns, E. M., Hull, L., Mayer, E., Sevdalis, N., & Darzi, A. (2017). International recommendations for national patient safety incident reporting systems: an expert Delphi consensus-building process. BMJ quality & safety, 26(2), 150-163.
Karmila, K., Suharni, S., & Alwi, M. K. (2023). Hubungan Budaya Keselamatan Pasien dengan Pelaporan Insiden Keselamatan Pasien oleh Perawat di Instalasi Rawat Inap Rumah Sakit TK II Pelamonia Makassar. Journal of Muslim Community Health, 4(1), 181-189.
Ko, E. S., & Kang, K. J. (2023). Effects of nurses' incident reporting attitude, perception of importance on patient safety management, and patient safety culture on the reporting of patient safety events. Journal of Korean Academy of Nursing Administration, 29(3), 309-319.
Lestari, E. A., & Fitriani, A. D. (2022). Analisis Faktor Penyebab Rendahnya Pelaporan Insiden Keselamatan Pasien Di Rawat Inap RSU Mitra Medika Bandar Klippa Tahun 2021. Journal of Healthcare Technology and Medicine, 7(2), 891–915.
Marselina, E. V., Prayitno, H., & Ismara, K. I. (2023). Dimensi Budaya Keselamatan Pasien dan Insiden Keselamatan Pasien di RS X Kota Malang. Jurnal Penelitian Kesehatan" SUARA FORIKES"(Journal of Health Research" Forikes Voice"), 14(2), 275-279.
Oweidat, I., Al-Mugheed, K., Alsenany, S. A., Abdelaliem, S. M. F., & Alzoubi, M. M. (2023). Awareness of reporting practices and barriers to incident reporting among nurses. BMC nursing, 22(1), 231.
Pramesona, B. A., Sukohar, A., Taneepanichskul, S., & Rasyid, M. F. A. (2023). A qualitative study of the reasons for low patient safety incident reporting among Indonesian nurses. Revista Brasileira de Enfermagem, 76(4).
Rachmawati, I., Satar, Y. P., & Indrajaya, T. (2025). Determinan Yang Mempengaruhi Pelaporan Insiden Keselamatan Pasien Pada Perawat Rawat Inap Rsud Cilincing. Jurnal Manajemen dan Administrasi Rumah Sakit Indonesia (MARSI), 9(4), 772-781.
Shemsu, A., Dechasa, A., Ayana, M., & Tura, M. R. (2024). Patient safety incident reporting behavior and its associated factors among healthcare professionals in Hadiya zone, Ethiopia: A facility based cross-sectional study. International Journal of Nursing Studies Advances, 6, 100209.
Stavropoulou, C., Doherty, C., & Tosey, P. (2015). How effective are incident‐reporting systems for improving patient safety? A systematic literature review. The Milbank Quarterly, 93(4), 826-866.
Suparjo, D., Paramarta, V., & Rulia, R. (2025). Pengaruh Gaya Kepemimpinan, Kerja Tim dan Budaya Keselamatan Pasien terhadap Pencapaian Sasaran Keselamatan Pasien (Patient Safety) di Rumah Sakit Umum Daerah Majalengka. AKADEMIK: Jurnal Mahasiswa Ekonomi & Bisnis, 5(2), 660-674.
Tolobisa, P. (2024). Exploring factors influencing patient safety incident reporting by nurses in primary health care facilities in King Sabata Dalindyebo sub-district, Eastern Cape (Doctoral dissertation).
Utami, K. C., Jak, Y., & Pangkey, D. Y. (2023). Pengaruh Budaya Keselamatan Pasien Terhadap Sikap Melaporkan Insiden Keselamatan Pasien di Rumah Sakit Mandaya Karawang. Jurnal Manajemen Dan Administrasi Rumah Sakit Indonesia (MARSI), 7(2), 125-136.
Yarnita, Y., & Efitra, E. (2020). Analisis Faktor yang Berhubungan dengan Budaya Keselamatan Pasien pada Perawat di Ruang Rawat Inap RSUD Arifin Achmad Provinsi Riau. Jurnal Ilmiah Universitas Batanghari Jambi, 20(3), 827-833.
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