Case Study : Incident Reporting

Modul : Patient Safety: Initiatives to Improve Patient Safety Following Patient Harm Events
Module

1. How would you determine what are the key barriers to incident reporting in your
organisation? (250 words)
There are several main barriers to reporting incidents in my working area, including:
- There is still a blaming culture in the workplace, which can cause trauma for staff and
make them afraid to report patient safety incidents.
- There is punishment that will be received by staff, specifically, they face punishment
from their leaders and fear of losing trust from their leaders, both of which have an
impact on their performance appraisal.
- Lack of reporting culture due to staff not understanding the importance of reporting
culture, lack of understanding of what incidents should be reported, also still assuming
the incidents can be handled. For example, near miss events. In general, socialization or
education is needed to increase understanding staff
- Lack of support from the unit leader, beginning with negative feedback or the
leadership's disregard for his staff.
- Staff who were not involved in the incident but saw that they were afraid to report for fear
of badmouthing their co-workers or other professions, and felt that it was not their job
because they were not involved in the incident
- Busy work that causes staff to be late and even forget to report the patient safety
incident
- Staff are afraid to be questioned and interviewed and asked for an explanation by their
leaders when reporting patient safety incidents

2. What is the level of leadership support for incident reporting and other safety
initiatives in your organisation? Does this need improving and how will you know that
it has improved? (250 words)
In order to improve patient safety in my organization, the most important thing is the
policy that governs the patient's safety, also the policy regarding the reporting flow of the
patient safety incident. Then, there is a patient safety team or committee that is trusted to
manage patient safety. Patient safety is not only the responsibility of the patient safety
 team/committee, but patient safety is the responsibility of all parties in the hospital. Top
management such as the main director and his staff always provide positive feedback
regarding reporting of patient safety incidents in hospitals, but just, lack of direct monitoring
and supervision in the field to see the state of services directly, hearing about complaints
directly from staff, suggestions and input to management, so that the directors see from the
patient safety reports, do not see directly due to busy work that can not be avoided. The most
of of middle managers have been exposed to what patient safety is and how it is reported,
but its implementation is still not optimal due to a variety of factors such as ineffective
communication with their staff, a lack of monitoring, and a lack of coordination with their staff.
In some cases, patient safety incidents reoccur, which can be caused by one of several
factors, including a failure to implement the feedback and recommendations provided by the
patient safety team after the RCA has been completed in the relevant unit, which causes
delays in improving the quality of hospital quality. For front-line managers, who go down
directly to see that the service process is also not optimal, There's a few who do not
understand patient safety and the reporting flow, are less responsive when incidents occur,
and as a result, many incidents just get unreported or are reported too late. As a result, when
incidents such as sentinels or adverse events occur and data is required, they have forgotten
how the actual incident caused delays in the repair process and may also cause the incident
to occur again in their unit.
To improve and increase patient safety, patient safety culture must be instilled in
everyone in the hospital, must have an understanding that patient safety is very important, so
strong leadership is needed, good communication between leaders and staff and also co
workers. Coordination between leaders and staff together to build a culture of patient safety,
by building a reporting culture, just culture and learning culture so that incidents are reduced
and can increase patient and community trust.

3. What are the processes for responding to incidents in your organisation at ward,
department and organisation levels? How effective are they? (250 words)

To respond to a safety incident in my organization, first of all, we have a policy regarding

incident reporting flows. Incidents are reported on the application by anyone involved, including
anyone who witnesses a patient safety incident; in simplest form, the application is accessible to
anyone from staff to managers. The report will be received by the patient safety team, assessed
for probability and impact, and graded. If the grading is blue or green, a simple investigation will
be carried out by the head of the relevant unit, if the grading is yellow or red, a direct and
thorough investigation will be carried out by the pre-determined investigation team. To respond
to this, a meeting will be held with various multi-professional parties which the patient safety
team believes can help to solve it. For sentinel incidents, the head of the patient safety team, as
well as the chair of the quality committee report the incident to the chief director, and further
sentinel incidents must be reported to the National Committee for Patient Safety and the
Hospital Accreditation Commission. RCA is a method used to find the root cause of incidents
that are categorized as yellow or red grading and are resolved within 45 calendar days. Then
the RCA report will be reported to the president director, the supervisory board, the National
Patient Safety Committee and the Hospital Accreditation Commission. Feedback is always
given by the main director and the board of directors, by instructing them to always monitor the
follow-up results obtained. Top management always provides feedback on patient safety
incident reports, front-line managers and middle managers still need to improve their
understanding of patient safety and the flow so that they can run more optimally and make
continuous improvements to hospitals.