Apa Faktor yang Berkontribusi Terhadap Pelaporan Insiden Keselamatan Pasien di Rumah Sakit? Systematic Review
DOI:
https://doi.org/10.32524/jksp.v8i3.1691Keywords:
Factors related, Patient safety, Reporting, NurseAbstract
Patient safety incidents are the third leading cause of death worldwide. Reporting all incidents is essential to identify problems and develop solutions based on root causes. However, underreporting of medical errors remains a major challenge in improving patient safety. This study aims to examine the factors influencing the reporting of patient safety incidents through a systematic review. The method used follows the PRISMA guidelines, with the aid of Zotero software. Article searches were conducted through PubMed, Science Direct, and ResearchGate databases using a PICO strategy and specific keywords. Out of 15,314 articles identified, only five met the inclusion criteria after a rigorous screening process. The analysis revealed that incident reporting is influenced by various factors, such as managerial support, training, communication, and organizational culture. In addition, there are other factors that are less explored, including perceptions of reporting, fear of peer judgment, time required to fill out reporting forms, and the influence of leadership. These aspects remain debated in the literature. Therefore, further research is needed to explore the barriers and enablers of patient safety incident reporting, particularly among nurses and healthcare professionals in hospital settings.
References
Abdelaliem, S.M.F. and Alsenany, S.A., 2022. Factors affecting patient safety culture from nurses’ perspectives for sustainable nursing practice. Healthcare (Basel), 10(10). https://doi.org/10.3390/healthcare10101889.
Al-Worafi, Y., 2023. Patient safety in developing countries: Education, research, case studies.
Aljabari, S. and Kadhim, Z., 2021. Common barriers to reporting medical errors. TheScientificWorldJournal, 2021, Article ID 6494889. https://doi.org/10.1155/2021/6494889.
Dhamanti, I., Leggat, S., Barraclough, S. and Rachman, T., 2021. Factors contributing to under-reporting of patient safety incidents in Indonesia: Leaders’ perspectives. F1000Research, 10, p.367. https://doi.org/10.12688/f1000research.51912.2.
Dhingra-Kumar, N., Brusaferro, S. and Arnoldo, L., 2021. Patient safety in the world. In: L. Donaldson, W. Ricciardi, S. Sheridan and R. Tartaglia, eds. Patient safety. Cham (CH), pp.93–98.
Dirik, H.F., Samur, M., Intepeler, S.S. and Hewison, A., 2019. Nurses’ identification and reporting of medication errors. Journal of Clinical Nursing, 28(5–6), pp.931–938. https://doi.org/10.1111/jocn.14716.
Farley, D.O., Haviland, A., Champagne, S. and Battles, J., 2021. The role of incident reporting in patient safety improvement. BMJ Quality & Safety, 30(2), pp.157–163.
Garcia, C.L., de Abreu, L.C., Ramos, J.L.S., de Castro, C.F.D., Smiderle, F.R.N., Dos Santos, J.A. and Bezerra, I.M.P., 2019. Influence of burnout on patient safety: Systematic review and meta-analysis. Medicina (Kaunas), 55(9). https://doi.org/10.3390/medicina55090553.
Gong, Y., 2022. Challenges and opportunities of patient safety event reporting. Studies in Health Technology and Informatics, 291, pp.133–150. https://doi.org/10.3233/SHTI220014.
Gong, Y., Kang, H., Wu, X. and Hua, L., 2017. Enhancing patient safety event reporting: A systematic review of system design features. Applied Clinical Informatics, 8(3), pp.893–909. https://doi.org/10.4338/ACI-2016-02-R-0023.
Gqaleni, T.M.H. and Mkhize, S.W., 2024. Barriers to implementing patient safety incident reporting and learning guidelines in specialised care units, KwaZulu-Natal: A qualitative study. PLOS ONE, 19(3), e0289857. https://doi.org/10.1371/journal.pone.0289857.
Ika, C., Novieastari, E. and Nuraini, T., 2019. The role of a head nurse in preventing interdisciplinary conflicts. Enfermería Clínica, 29(Suppl 2). https://doi.org/10.1016/j.enfcli.2019.04.019.
Jachan, D.E., Müller-Werdan, U. and Lahmann, N.A., 2021. Patient safety: Factors for and perceived consequences of nursing errors by nursing staff in home care services. Nursing Open, 8(2), pp.755–765. https://doi.org/10.1002/nop2.678.
Kohn, L.T., Corrigan, J.M. and Donaldson, M.S., 2000. To err is human: Building a safer health system. Washington, DC: National Academy Press.
Kissinger, Y.E. and Wulandari, C.I., 2023. Analysis of implementing nurse workload in evaluating nurse requirements in X Hospital: Literature review. Media Publikasi Promosi Kesehatan Indonesia, 6(10). https://doi.org/10.56338/mppki.v6i10.3851.
Roussel, L., Swansburg, R.J. and Swansburg, R.C., 2021. Management and leadership for nurse administrators. 4th ed. Jones & Bartlett Publisher.
Liukka, M., Steven, A., Vizcaya Moreno, M.F., Sara-Aho, A.M., Khakurel, J., Pearson, P., Turunen, H. and Tella, S., 2020. Action after adverse events in healthcare: An integrative literature review. International Journal of Environmental Research and Public Health, 17(13). https://doi.org/10.3390/ijerph17134717.
Mahdaviazad, H., Askarian, M. and Kardeh, B., 2020. Medical error reporting: Status quo and perceived barriers in an orthopedic center in Iran. International Journal of Preventive Medicine, 11, p.14. https://doi.org/10.4103/ijpvm.IJPVM_235_18.
Makary, M. and Daniel, M., 2016. Medical error—the third leading cause of death in the US. BMJ, 353, i2139. https://doi.org/10.1136/bmj.i2139.
Panesar, S. and Forbes, E., 2009. Being open: Communicating patient safety incidents with patients, their families and carers.
Prentice, J.C., Bell, S.K., Thomas, E.J., Schneider, E.C., Weingart, S.N., Weissman, J.S. and Schlesinger, M.J., 2020. Association of open communication and the emotional and behavioural impact of medical error on patients and families: State-wide cross-sectional survey. BMJ Quality & Safety, 29(11), pp.883–894. https://doi.org/10.1136/bmjqs-2019-010367.
Reason, J., 2000. Human error: Models and management. BMJ, 320(7237), pp.768–770. https://doi.org/10.1136/bmj.320.7237.768.
Sehgal, A., 2024. What is the effectiveness of reporting systems in promoting learning in healthcare? British Journal of Hospital Medicine, 85(4), pp.1–9. https://doi.org/10.12968/hmed.2023.0444.
Shemsu, A., Dechasa, A., Ayana, M. and 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. https://doi.org/10.1016/j.ijnsa.2024.100209.
Wagner, L.M., Capezuti, E. and Rice, J.C., 2020. Barriers to nursing home error reporting. Journal of Nursing Care Quality, 35(1), pp.55–61.
Wanda, N. and Wahyudi, A.S., 2020. Analysis of factors affecting reporting of patient safety incidents in nurses. Fundamental and Management Nursing Journal, 3(1). http://dx.doi.org/10.20473/fmnj.v2i2.17284.
World Health Organization (WHO), 2020. Patient safety incident reporting and learning systems: Technical report and guidance. Geneva. https://iris.who.int/bitstream/handle/10665/334323/9789240010338-eng.pdf?sequence=1.
World Health Organization (WHO), 2019. Patient safety: Global action on patient safety. Seventy-Second World Health Assembly A72.
Wulandari, C., Handiyani, H., Novieastari, E., Soemantri, D. and Rizany, I., 2024. Qualitative study: Nursing managers in managing nurse educators in hospitals. Salud, Ciencia y Tecnología, 4. https://doi.org/10.56294/saludcyt2024.1025.
Xiang, Z., Jin, Q., Gao, X., Li, X., Liu, H., Qiao, K. and Jiang, B., 2022. Perception of patient safety and the reporting system between medical staffs and patients in China: A cross-sectional online study. Journal of Patient Safety, 18(1), pp.e297–e307. https://doi.org/10.1097/PTS.0000000000000773.
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