Tata Sutabri, Evi Nopiyanti, Firman Syah Alam, Agus Joko Susanto, Ninik Setyowati.


Patient safety is patient free from injury that is not supposed to occur or free from potential hazards that will occur incidents, like as Potential Injury Conditions, Non-Injury Events, Near Injuries, Events Not expected, and sentinel events. All incidents that occur must be reported and found the root cause. Hospital X has implemented a patient safety program, but still shows the standards set cannot be fulfilled, there are many events that have the potential to cause harm and even threaten safety patient, and investigative analysis has not been carried out to find the root cause. The purpose of this study is to find out the main cause of the investigation of the incidence of patient safety at X Hospital. Cases found with yellow (high) and red (extreme) risk degrees were carried out with a comprehensive investigative analysis using the Root Cause Analysis (RCA) method, using the help of fishbone diagrams, univariate analysis was also conducted to determine the frequency distribution of each incident that occurred. There were 10 incidents of patients falling (26.3%) consisting of 6 cases falling out of bed, 2 cases falling in the toilet, and 2 cases falling in the corridor. Based on the results of the assessment of risk bands, including the red (extreme) category. The results of the investigation found that the main cause was an installed safety bed fence and a slippery toilet floor. The incidence of falling patients is caused by the bed safety fence that is not installed and the floor is slippery. 

Keywords: investigation, incident, patient safety


investigation, incident, patient safety

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