JRSSEM 2022, Vol. 01, No. 8, 1103 – 1117
E-ISSN: 2807 - 6311, P-ISSN: 2807 - 6494
DOI : 10.36418/jrssem.v1i8.67 https://jrssem.publikasiindonesia.id/index.php/jrssem/index
FACTORS AFFECTING PATIENT SAFETY INCIDENT
REPORTING
Galuh Meifika Fathiyani1*
Dian Ayubi2
1Masters Program in Public Health, Faculty of Public Health, University of Indonesia
2Faculty of Public Health, University of Indonesia
e-mail: galuhmeifika@gmail.com1, dian.ayubi@gmail.com2
*Correspondence: galuhmeifika@gmail.com
Submitted: 15 February 2022, Revised: 04 March 2022, Accepted: 15 March 2022
Abstract. Patient safety incident reporting is one of the steps taken needed to improve patient
safety. Reporting can provide a broad picture of the incident and how it happened. This can be
used as basic data for policy making and making patient safety programs in hospitals. The subjects
in this study were health workers. This research method uses a systematic review, from various
sources of research that has been done previously. The databases used in this study are Science
Direct, Scopus and SpringerLink, journals published from January 2011 to December 2021 which
were then extracted using PRISMA 2009 flowcharts. So that the final results were 11 journals that
were reviewed. This study resulted in reporting patient safety incidents influenced by individual
factors, group/unit factors and organizational factors. The conclusion of this study is that incident
reporting can be improved by evaluating and improving individual factors, group/unit factors and
organizational factors
Keywords: reporting; incidents; patient safety.
Galuh Meifika Fathiyani, Dian Ayubi | 1104
DOI : 10.36418/jrssem.v1i8.67 https://jrssem.publikasiindonesia.id/index.php/jrssem/index
INTRODUCTION
Health services are the result of
interactions between customers and
providers that cannot be seen with the
naked eye, but the benefits can be felt
(Garcia-Fernandez, Bernal-Garcia,
Fernandez-Gavira, & Velez-Colon, 2014).
The results of the service in question can be
in the form of satisfaction and benefits
obtained from service providers and
recipients (Kotler & Armstrong, 2010). One
of the requirements for health services is
quality (Putri & Isnani, 2015). Components
of service quality or the quality of health
services themselves are translated into
components of structure, process and
outcome (Schulze et al., 2017). Patient
safety plays an important role in improving
quality and reducing risks to health
workers, non-health workers, risks from
facilities and infrastructure, financial risks,
and others (Feng, Acord, Cheng, Zeng, &
Song, 2011). Quality in safety is used to
identify the level of risk and undesirable
events so that they can be avoided and
minimized through continuous assessment.
Quality is a continuation of health services
to patients, both individually and in groups.
Safety (patient safety) is one of the
dimensions of service quality according to
IOM (Istiqomah, Listyorini, & Yuliani, 2021).
The hospital is a health service place
that has multi-professional characteristics
and multi-risk factors, so a system is
needed that can protect patient safety in
hospitals. Improving the quality of
hospitals by increasing patient safety can
provide benefits for both hospitals and
patients. The step towards patient safety is
the implementation of patient safety
incident reporting. Reporting patient safety
incidents can reduce the risks that arise as
a result of an incident, can improve patient
safety and be used as a basis for designing
programs that are centered on patient
safety issues (Mjadu & Jarvis, 2018).
Medical incident reporting is also
considered an important element in
improving patient safety and quality of
care, so it should be made an integral part
of the organizational culture (AbuAlRub,
Al-Akour, & Alatari, 2015).
Reporting patient safety incidents can
reduce risks that may occur during service
delivery, so that the number of incoming
complaints can be minimized, costs due to
the impact of incidents will be smaller and
most importantly patient satisfaction will
increase. Increasing patient satisfaction
with good safety quality will also increase
public trust in hospitals, so that people can
get optimal health services with minimal
risk and hospitals gain trust with a good
image.
METHODS
The systematic review in this study uses
PRISMA (Preferred Reporting Items for
Systematic Reviews and Meta-Analyzes)
with the PICOS approach in research
formulation, inclusion and exclusion
criteria. The databases used are journals
from Science Direct, Scopus and
Springerlink. This is done to obtain relevant
and credible journals. The inclusion criteria
for this study included scientific journals
with the theme of patient safety incident
reporting published on January 1, 2011 –
December 2021, in English, with all study
types and the population being hospital
1105 | Factors Affecting Patient Safety Incident Reporting
staff. The keywords in article search were:
“Patient safety incident” AND “incident
reporting” OR “medical error reporting”
AND “factors related to incident” AND
“hospital”. The selected article is an article
that aims to determine the factors that are
related to (influence or hinder) the
reporting of patient safety incidents. The
research is not limited to a particular area,
only limited to hospital employees and is
not a systematic review. The search resulted
in 512 journals in Science Direct, 22 journals
in Scopus and 426 journals in Springer Link.
In accordance with the PRISMA diagram,
the next search is the filtering of journals
which are duplicates of 73 journals. The
search was continued by filtering titles and
abstracts that matched the topic of
discussion, and 861 titles were not
appropriate and 15 journals were
systematic reviews.
Galuh Meifika Fathiyani, Dian Ayubi | 1106
DOI : 10.36418/jrssem.v1i8.67 https://jrssem.publikasiindonesia.id/index.php/jrssem/index
Figure 1. PRISMA FLOW DIAGRAM
Science
Direct (n=
512 )
Scopus
(n= 22)
Records after duplicates
removed (n=887)
Full text article
(n= 11)
Studies include in qualitative
synthesis
(n= 11)
Records exclude(n=876)
Not compliant with PICO (n=861 )
Systematic review/studi protocol (n=
15)
Include
Total (n=960)
Spinger
Link
(n= 426)
1107 | Factors Affecting Patient Safety Incident Reporting
Table 1. Summary of Research Results
Author Name
(Year)
Title
of Research
Method
Sample/Research
Population
Research
Location
Results
(Haller,
Courvoisier,
Anderson, &
Myles, 2011)
Clinical factors
associated with the
non-utilization of an
anesthesia incident
reporting system
Retrospective
cohort of
46,207 surgical
patients
The Alfred Hospital
(Melbourne,
Australia)
Factors influencing reporting are
clinical environment, team
composition, severity of incident
and perceived risk of litigation
(Alzahrani, Jones,
& Abdel-Latif,
2018)
Attitudes of doctors
and nurses toward
patient safety within
emergency
departments of two
Saudi Arabian
hospitals
Cross-
Sectional
503 IGD doctors
and nurses
Hospitals in Saudi
Arabia
Teamwork, job satisfaction and
performance have a negative
relationship with patient safety
incident reporting rates
(Vermeulen,
Kleefstra, Zijp, &
Kool, 2017)
Understanding the
impact of
supervision on
reducing
medication risks: an
interview study in
long-term elderly
care
Mix method:
Qualitative
with semi-
structured
interviews
Quantitative
with risk
Health care
professionals from
ten
Dutch
Implementation of supervision
increases willingness to report
patient safety incidents
(Gong, Song, Wu,
Identifying barriers
with semi-
Texas Medical Center
The barriers to incident reporting
Galuh Meifika Fathiyani, Dian Ayubi | 1108
& Hua, 2015)
and benefits of
patient safety event
reporting toward
user-centered
design
structured
interviews at
were lack of instruction and
training, lack of knowledge, lack of
time and lack of feedback
.
(Polisena,
Gagliardi, &
Clifford, 2015)
How can we
improve the
recognition,
reporting and
resolution of
medical device-
related incidents in
hospitals? A
qualitative study of
physicians and
registered nurses
Qualitative
with semi-
structured
interviews
Doctors and nurses
Ottawa, Toronto,
Canada
Incident reporting is influenced by
error rate, physician's personal
attitude, and feedback received on
reported errors
(Naome, James,
Christine, &
Mugisha, 2020)
Practice, perceived
barriers and
motivating factors
to medical-incident
reporting: a cross-
section survey of
health care
providers at
Mbarara regional
referral hospital,
Cross sectional
158 health workers
Mbarara Regional
Referral Hospital
(MRRH), Western
Uganda encouraging patient safety
incident reporting is the
establishment of a communication
system, corrective action for
incidents, good knowledge
Factors that hinder patient safety
incident reporting are lack of
knowledge about incidents and
reporting, no incident reporting
team, fear of being punished
1109 | Factors Affecting Patient Safety Incident Reporting
southwestern
Uganda
(Tuffrey-Wijne et
al., 2014)
The challenges in
monitoring and
preventing starch
ent safety incidents
for people with
intellectual
disabilities in NHS
acute hospitals:
evidence from a
mixed-methods
study
Mix method
consisting of
interviews,
observation
and
monitoring
and
distributing
questionnaires
to clinical hospital
staff (n = 990);
questionnaire to
guardians (n = 88);
interviews with:
hospital staff
including senior
managers, nurses
and doctors (n = 68)
and caregivers (n =
37); observation of
inpatients with
intellectual
disabilities (n = 8);
monitoring incident
reports (n = 272)
and complaints
involving persons
with intellectual
disabilities
NHS acute hospitals
Events leading to avoidable
hazards are not recognized as
safety incidents and the absence of
an effective system for monitoring
incidents prevents reporting
(Hewitt, Chreim, &
Forster, 2016)
Incident reporting
systems: a
comparative study
Qualitative
with semi-
structured
of 85 health workers
at
Hospital X
Things that affect the patient safety
incident reporting process are
litigation, training/knowledge on
Galuh Meifika Fathiyani, Dian Ayubi | 1110
of two hospital
divisions
interviews
patient safety incident reporting
and teamwork
(El-Jardali,
Dimassi, Jamal,
Jaafar, &
Hemadeh, 2011)
Predictors and
outcomes of patient
safety culture in
hospitals
Cross sectional
67 Hospitals and
6,807 hospital staff
Private Hospitals in
Lebanon
Factors that enhance reporting of
patient safety incidents are
feedback and communication
regarding errors,
supervisor/manager expectations
and actions to promote patient
safety, organizational learning and
continuous improvement, and
teamwork within hospital units
(Mjadu & Jarvis,
2018)
Patients' safety in
adult ICUs:
Registered nurses'
attitudes to critical
incident reporting
descriptive
quantitative
non-
experimental
127 ICU nurses
at a tertiary
provincial hospital in
KwaZulu-Natal,
South Africa
Managerial support can improve
reporting of critical incidents
Unpleasant collegial atmosphere is
associated with reporting of
patient safety incidents
(Nada J. Alsaleh,
2020)
Adverse drug
reaction reporting
among physicians
working in private
and government
hospitals in Kuwait
Cross-sectional
1045 doctors
Hospitals in Kuwait
Factors that hindered reporting IKP
were lack of knowledge about how
to report, absence of a reporting
system, perception that reporting
was unimportant, lack of awareness
and commitment to reporting, lack
of time
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Table 2. Grouping of factors that affect reporting of patient safety incidents in hospitals
Individual
Factors Group/Team
factors Organizational
factors
Lack of individual knowledge
about the classification of
patient safety incidents
makes it difficult for
individuals to understand
between the definition of
incident categories and
practice in the field, in
addition, knowledge of how
to report also affects incident
reporting. patient safety
Individual perceptions of
events that do not result in
injury or potentially
hazardous events but can be
prevented leading to
incidents not being reported
Litigation raises concerns
and fears of license
revocation and penalties for
individuals so that not
discourage individuals from
reporting
Very high threat of litigation
in the service sector with
elements of special effort on
the contrary becomes a great
motivation for reporting
Individual personal attitudes
Lack of time to report,
awareness and commitment
to reporting makes
individuals not reporting
Unpleasant team
atmosphere associated with
patient safety incident
reporting
Team work within hospital
units increases the likelihood
of reporting
Supervision increases
willingness to report patient
safety incidents
Clinical environment and
team composition influence
reporting
Training on interpersonal
teams and communication
initiatives encourages
incident reporting
Reporting systems are
considered essential for
running the incident
reporting process
Absence of an effective
system for monitoring
incidents leads to incidents
not being reported
No incident reporting team
hinders reporting
Establishment of
communication system
encourages pel Reporting
Culture within the
organization which includes
feedback and
communication regarding
errors, supervisor/manager
expectations and actions to
promote patient safety,
organizational learning and
continuous improvement
improving patient safety
incident reporting, taking
corrective actions regarding
incidents encouraging
reporting,
Training to increase
knowledge aimed at
introducing individuals
regarding the reasons why
reporting is important
. Unclear instructions
regarding reporting
Galuh Meifika Fathiyani, Dian Ayubi | 1112
RESULTS AND DISCUSSION
The search results of 11 journals that
met the research criteria. The criteria used
are in accordance with the PRISMA
(Preferred Reporting Items for Systematic
Reviews and Meta-Analyzes) flowchart.
Journal publications used are publications
in 2020 totaling 1 article, 2018 totaling 2
articles, 2017 totaling 2 articles, 2016
amounting to 1 article, 2015 totaling 2
articles, 2014 totaling 1 article and 2011
totaling 2 articles. There are 1 article
published on Scopus, 2 articles published in
Science Direct, 8 articles published on
SpringerLink. The 11 selected articles are
research conducted in Australia, Saudi
Arabia, Netherlands, Texas, Canada,
Ottawa, Toronto, Uganda, UK, South Africa,
Lebanon and Kuwait. The search results
show that there are several factors that
influence the reporting of patient safety
incidents, both factors that can increase
and factors that can hinder reporting of
patient safety incidents. The summary of
the research results is presented in
Table 1. Patient safety incident reports
are carried out by the hospital staff who
first discovered the incident or the staff
involved in the incident. This is the basis
that reporting must be carried out by
hospital staff. Reporting patient safety
incidents is staff behavior that affects
organizational performance, especially
regarding hospital patient safety. It is
known that staff behavior is the behavior of
individuals in the organization (hospital).
Organizational behavior is the study of
what people do in an organization and how
their behavior affects organizational
performance (McShane & Glinow, 2017). So
that organizational behavior is very
centered on situations related to work, it is
emphasized that behavior in relation to
work, work, absenteeism, employee
turnover, productivity of human
performance and management.
Organizational behavior itself is examined
in three levels of analysis, namely
individuals, groups and organizations as a
system (Purba et al., 2020). Individual
behavior in the organization can not be
separated from the influence obtained
from the work environment and the
organization within the agency. So that the
behavior of reporting patient safety
incidents needs to be seen from the
variables related to the group/team as well
as the organization. Factors that affect the
reporting of safety incidents seen from the
concept of behavior in the organization are
divided into three analyzes, namely
individual analysis, group/unit analysis and
organizational analysis.
Individual
Individual factors are factors that come
from within the individual to report an
incident. Individual factors in the
organization are seen from the diversity
that includes background and
demographics, personality, abilities and
skills, motivation, perception and decision
making (Gibson, Ivancevich, & Konopaske,
2011). The individual factor has a close
relationship with reporting, because the
individual is the subject who does the
reporting. The first individual factor is
knowledge, the knowledge that individuals
need to have in reporting patient safety
incidents is knowing about events
categorized as incidents, then classifying
1113 | Factors Affecting Patient Safety Incident Reporting
incidents (Gong et al., 2015); (Naome et al.,
2020); (Hewitt et al., 2016); (F. M. Alsaleh et
al., 2017). Lack of knowledge about this will
make individuals unable to report patient
safety incidents.
The second individual factor is
individual perception, this perception is
described in several ways, the most
frequent of which is the fear of a lawsuit to
the revocation of the practice license
(Naome et al., 2020); (Hewitt et al., 2016).
Other perceptions that influence reporting
are the perception that events that can
cause harm and can be prevented are not
incidents that need to be reported and the
perception that reporting is not an
important thing to do (Tuffrey-Wijne et al.,
2014); (F. M. Alsaleh et al., 2017). Perception
is a psychological factor that can influence
individual behavior, so it can be seen that
an individual does something based on the
perception he has of it, where a negative
perception will make the individual not
want to behave in a certain way. The next
factor is that individuals feel they have less
time and awareness and individual
commitment to reporting related to
reporting patient safety incidents (F. M.
Alsaleh et al., 2017).
Group/Team Factors
Analysis of individual behavior in the
next organization is an analysis of groups
and teams that make individuals report
patient safety incidents. Teamwork(or team
behavior) is a dynamic process involving
two or more people involved in the
activities required to complete a task
(World Health Organization, 2020). From
the study of group behavior, it is known
that being a member of a work team can
affect individual behavior. The factors that
influence the reporting of patient safety
incidents from group analysis are
teamwork and team leadership (Verbano &
Turra, 2010). Teamwork in this study is
known to the atmosphere in the team,
teamwork within the unit, clinical
environment and composition in the team
affect the reporting of patient safety
incidents (Mjadu & Jarvis, 2018); (Alzahrani
et al., 2018); (Coutts, Piola, Hewitt, Connell,
& Gardner, 2010); (Alswat et al., 2017);
(Haller et al., 2011). Individuals who have
teamwork will make them more obedient
to the rules and SOPs in the unit, so that
mistakes and actions taken independently
can be monitored and there will be a
process of reminding and correcting each
other between individuals. This process will
increase individual awareness and
encouragement to report IKP as a lesson
for the future. Training on interpersonal
teams and communication initiatives
should also be implemented to encourage
incident reporting.
This study illustrates that supervision is
needed to encourage patient safety
incident reporting (Vermeulen et al., 2017).
Supervision needs to be carried out by the
leadership/supervisor team which is useful
for monitoring individual activities in the
unit/group. Team leadership/supervisor is
the person who is appointed, selected or
chosen informally to direct and coordinate
the work of others in a group (Mumford,
Todd, Higgs, & McIntosh, 2017). Team
leadership needs to monitor and
strengthen workers' safe behavior,
emphasize safety over productivity,
participate in safety activities, and
encourage employee involvement in safety
Galuh Meifika Fathiyani, Dian Ayubi | 1114
initiatives (Wagner et al., 2019).
Organizational Factors Organizational
Factors or organizational behavior are
factors that invest in the influence of
individuals, groups and structures on
behavior within organizations for the
purpose of increasing organizational
effectiveness (Elangovan, Pinder, &
McLean, 2010). Organizational factors that
influence individual behavior are systems
and structures, regulations, culture and HR
management. In the system, it is known
that the existence of a structured reporting
system will help individuals to report more
easily. The structure and system designed is
a structure and system that facilitates the
reporting process, this will reduce the
reason for the absence of time for reporting
by individuals. Another system that is
needed is a system that can actively and
effectively monitor an incident in all
hospital units (Tuffrey-Wijne et al., 2014).
This system will encourage all incidents or
incidents to be recorded and known easily
by all individuals in the hospital agency, so
that incidents in various groups that result
in injury or have the potential to cause
injury can be identified. This will encourage
individuals to report incidents and get rid
of the individual's perception of the
reported incident being an incident that
resulted in injury. A good communication
system will also encourage reporting of
patient safety incidents (Naome et al.,
2020). Good communication will train
individuals to have the courage to report.
The existence of a reporting team structure
will greatly assist individuals in reporting.
Organizational culture that influences
reporting in this study are feedback and
communication, supervisor/manager
expectations and actions to promote
patient safety, organizational learning and
improvement, corrective action, managerial
support (Mjadu & Jarvis, 2018); (El-Jardali
et al., 2011). Implementation of
organizational learning in fostering a
culture of patient safety is one of the active
activities that can foster values in the
organization (Schermerhorn Jr, Osborn,
Uhl-Bien, & Hunt, 2011). So that the
implementation of this activity needs to be
considered and used as a way to improve
the existing patient safety culture.
Feedback and communication about errors
is an aspect that describes a patient safety
culture where every individual in the
organization can get information and
access information on a finding or incident
feedback and communication about errors
comprehensiveProviding feedback is one
of the principles in responding to patient
safety incident reports. The expected
managerial support is supported with clear
regulations and instructions regarding
incidents, incident reporting that is
specifically stated in SOPs, as well as
guidelines for each unit in the hospital. This
is to encourage units to know what hazards
or risks as well as incidents may occur in
their units and to reduce risks arising from
incidents. The existence of training
designed by the organization can also
improve incident reporting by individuals,
where training is one way for organizations
to manage their human resources and is an
input stage that the organization needs to
carry out. Training will make individuals
more skilled, in addition to increasing
knowledge about incident reporting.
1115 | Factors Affecting Patient Safety Incident Reporting
CONCLUSIONS
Reporting patient safety incidents is an
important process in order to improve
patient safety. The results obtained in an
effort to improve patient safety is an
increase in the quality of service. Improving
the quality of service in the end will provide
benefits for the patient as a customer and
the hospital as a provider. For the customer,
good service quality will foster a feeling of
satisfaction with the services provided and
patients will avoid the many risks that may
occur during the health service process. On
the hospital side as a provider, the hospital
will benefit directly from patient
satisfaction, namely by increasing the
number of patients who use the services
offered. In addition, hospitals can reduce
unnecessary costs due to the impact of
incidents that occur. The purpose of
incident reporting is not to reduce the
number of incidents, because the more
incidents reported, the more serious risks
the hospital can minimize. In improving the
incident reporting process, it is necessary to
pay attention to the factors that can affect
reporting behavior by staff and employees
at the hospital. These factors cannot be
separated from individual factors, unit
environmental factors and organizational
factors themselves. Because it is a system
analysis of individual behavior in the
organization.
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