Analysis of Factors Influencing Near Miss Events in Hospitals in Indonesia: Literature Review
DOI:
https://doi.org/10.25311/keskom.Vol11.Iss1.2074Keywords:
Abstract
Background: The percentage of incidents recorded as KNC in Indonesia was 47.6%, higher than the percentage of incidents reported as KTD, which was 46.2%. One important effort in patient safety is to reduce Near Miss Events (NME), which can avoid serious injury to patients that impact the services provided. Aim: This study aims to identify factors that influence Near Miss Events in hospitals in Indonesia. Method: The study used a literature review method. Search with Garuda, Semantic Scholar, and Google Scholar databases. The article criteria were research conducted in Indonesia, publications in 2014 - 2024, full text, free access, original articles and an explanation of NME in them. Results: The search resulted in 6 articles that met the criteria and were then analyzed based on Donabedian's Theory. The research findings showed that in the structure factor, the competence of medical personnel and work environment conditions were significant factors. In the process factor, team communication and compliance with SOPs influenced the risk of NME. The outcome factor showed that NME had an impact on decreasing patient trust and service quality. Conclusion: The occurrence of KNC in hospitals in Indonesia is influenced by structural, process, and outcome factors, it is necessary to focus on improvements in hospital management, staff training, improving medical team communication, and implementing a patient safety culture to reduce the risk of recurrence of such incidents.
Downloads
References
[1] Aspden P, Corrigan JM, Wolcott J, & Erickson SM. Patient Safety: Achieving a New Standard For Care, National Academies Press. 2004.
[2] Azizah SD, & Rachmawati E. Analisis determinan kejadian nyaris cedera dan kejadian tidak diharapkan di Instalasi Gizi Rumah Sakit Anak dan Bunda Harapan Kita. Jukema, 2016; 2(1), 58-67.
[3] Berwick D, & Fox DM.“Evaluating the quality of medical care”: Donabedian's classic article 50 years later. The Milbank Quarterly, 2016; 94(2), 237.
[4] Flotta D, Rizza P, Bianco A, Pileggi C, & Pavia M. Patient Safety and Medical errors: knowledge, attitudes and behavior among Italian hospital physicians, 2018; 24(3), 258-265.
[5] Kemenkes RI. Permenkes Nomor 3 Tahun 2020 Tentang Klasifikasi dan Perizinan Rumah Sakit. 2020.
[6] Kemenkes RI. Permenkes Nomor 308 Tahun 2017 Tentang Keselamatan Pasien. 2017.
[7] KNKPRS. Laporan Insiden Keselamatan Pasien Rumah Sakit (Paltient Salfety Report). 2022.
[8] Mappanganro A. Faktor yang berhubungan dengan upaya pencegahan risiko jatuh oleh tenaga medis dalam patient safety di Ruang tenaga medis anak rumah sakit Bhayangkara Makassar. Jurnal Medika Hutama, 2020; 63-70.
[9] Melliany O. Penerapan Keselamatan Pasien Dalam Peningkatan Akreditasi Rumah Sakit. 2019.
[10] Salsabila AA, & Supriyanto S. Analisis Insiden Kejadian Nyaris Cedera Dan Kejadian Tidak Diharapkan di Rumah Sakit X Surabaya. Majalah Kesehatan Masyarakat Aceh (MaKMA), 2019; 2(3).
[11] Sihotang JL, Nababan D, Tarigan FL, Ginting D, & Manurung K. Faktor-Faktor yang Mempengaruhi Pelaksanaan Program Patients Safety oleh Perawat di Rumah Sakit Bhayangkara Tk III Tebing Tinggi. Journal of Healthcare Technology and Medicine, 2022; 7(2), 1010-1023.
[12] Sithi DS, & Widyastuti A. Contributing factor to incident of patient safety within implementing patient safety goal in inpatient Depok City Hospital Indonesia. Annals of Tropical Medicine and Public Health, 2019; 22(11), 316-324.
[13] Utami MR. Analysis Of The Nature Of Works To Near Miss Event At Caring Unit Of Cimacan General Hospital. In Prosiding Seminar Nasional & Internasional 2017 ; Vol. 1, No. 1.
[14] Wahyuni U, Andhini CD, & Supratini S. Hubungan Pelaksanaan Prinsip Pemberian Obat Dengan Kejadian Nyaris Cedera (KNC) Pada Pasien Rawat Inap Di Rumah Sakit Pelabuhan Cirebon. Jurnal Keperawatan Cikini, 2022; 3(2).
[15] WHO. Global Action on Patient Safety. 2018.
[16] Wibowo B. Pemahaman Mutu Dan Keselamatan Pasien Ditingkatkan Meminimalisir Harus Untuk Terjadinya Kesalahan Penanganan. 2018.
[17] Zuliardi. Analisis Faktor-Faktor Kejadian Nyaris Cedera dan Kejadian Tidak Diharapkan Di Rumah Sakit Umum Daerah Kota Mataram. 2017
[18] Adhelna, S., Jannah, N., Yusuf, M., Putra, A., & Yullyzar, Y. (2024). Studi Kasus Kejadian Nyaris Cedera (KNC) pada Pasien Risiko Jatuh. Jurnal Penelitian Tenaga medis Profesional, 6(4), 1417- 1426.
[19] Andhini, C. D., Wahyuni, U., & Supratini, S. (2022). Hubungan Pelaksanaan Prinsip Pemberian Obat Dengan Kejadian Nyaris Cedera (KNC) Pada Pasien Rawat Inap Di Rumah Sakit Pelabuhan Cirebon. Jurnal Keperawatan Cikini, 3(2).
[20] Debora, E., Dewi, W. N., & Dewi, Y. I. (2019). Hubungan pengetahuan tenaga medis tentang kejadian nyaris cedera dengan sikap melaporkan kejadian nyaris cedera. Jurnal Ners Indonesia, 8(2), 99-109.
[21] Sari, Y. (2023). Hubungan Pengetahuan dengan Kepatuhan Tenaga medis dalam Pelaksanaan Standar Prosedur Operasional Pencegahan Risiko Jatuh pada Pasien Di RSU Setia Budi: Field Research. Journal of Vocational Health Science, 2(1), 13-22.
[22] Sihombing, L. A. Peran Tenaga medis Tentang Insiden Nyaris Cedera Pada Pasien Di Rumah Sakit. 2020.
[23] Sriningsih, N. N., & Marlina, E. Pengetahuan Penerapan Keselamatan Pasien (Patient Safety) Pada Petugas Kesehatan. Jurnal Kesehatan, 2020; 9(1), 1-13.
[24] Wahyuni, A. Efektivitas Implementasi Sistem TBAK dalam Komunikasi Medis. Jurnal Komunikasi Kesehatan. 2014.
[25] Widyastuti, Y. Perilaku Kepatuhan Staf Medis terhadap SOP Pelaporan. Jurnal Kesehatan Masyarakat. 2018.
[26] PERSI. Pedoman Keselamatan Pasien Rumah Sakit. Jakarta: PERSI. 2015.
[27] Kusuma, H. Pengaruh Lingkungan Kerja terhadap Kinerja Perawat. Jurnal Psikologi Industri dan Organisasi. 2021.
[28] Sulistiyanto, H., Rosidawati, I., & Syarifuddin, D. Pengaruh Lingkungan, Beban dan Kompensasi Terhadap Kepuasan Karyawan Di RSIA Mutiara Bunda. Jurnal Kesehatan Kusuma Husada, 2024; 113-123.
Downloads
Submitted
Accepted
Published
How to Cite
Issue
Section
License
Copyright (c) 2025 Jurnal kesehatan komunitas (Journal of community health)
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
Copyright @2017. This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License (http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted non-commercial used, distribution and reproduction in any medium
