Abstract
(1) Background: A patient safety incident reporting system was introduced in Indonesian hospitals in 2006; however, under-reporting of patient safety incidents is evident. The government plays a vital role in the implementation of a national system. Therefore, this study focuses on how the Indonesian government has been undertaking its role in patient safety at provincial and city/district levels, including incident reporting according to the National Guideline for Hospital Patient Safety. (2) Methods: This study employed a qualitative approach with interviews of 16 participants from seven organizations. The data were managed using NVivo and thematically analyzed. (3) Results: The findings revealed several problems at the macro-, meso-, and micro-level as the government was weak in monitoring and evaluation. The District Health Office (DHO) and Provincial Health Office (PHO) were not involved in incident reporting, and there was a lack of government support for the hospitals. (4) Conclusions: The DHO and PHO have not carried out their roles related to patient safety as mentioned in the national guidelines. Lack of commitment to and priority of patient safety, the complexity of the bureaucratic structure, and a lack of systematic partnership and collaboration are problems that need to be addressed by systematic improvement. To ensure effective and efficient national outcomes, the three levels of government need to work more closely.
Highlights
Patient safety incident reporting systems provide information on the occurrence of patient safety incidents to mitigate risk, improve the system, learn from the mistakes, and share learning [1,2,3,4].Incident reporting in hospitals is usually governed by a national reporting system
In Indonesia, a patient safety incident reporting system was introduced in hospitals in 2006
Since the government plays a vital role in the implementation of a national system for improving patient safety, including tracking and monitoring patient safety incidents, this study focuses on how the Indonesian government has been undertaking its role in patient safety at the provincial and city/district levels
Summary
Incident reporting in hospitals is usually governed by a national reporting system. In Indonesia, a patient safety incident reporting system was introduced in hospitals in 2006. The government has published supporting regulations and guidelines such as the National Guidelines for Hospital. Patient safety implementation, including incident reporting, was handled by the National Committee on Patient Safety, the Indonesian Hospital Association (IHA), and the Commission for Hospital. Accreditation (CHA) [5] which is responsible for hospital accreditation and delivering patient safety training. Government organizations, such as the Ministry of Health and District Health Offices (DHO), carried out roles at the provincial and district/city levels, including advocacy for the patient
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