Implementation of Patient Safety Culture at Hospital X, Semarang City
Abstract
Patient safety incidents remain a persistent challenge in hospital settings, yet evidence on the cultural factors driving them in type C hospitals in Indonesia remains limited. Hospital X in Semarang City recorded 23 patient safety incidents from January to September 2023 (KTD: 2, KTC: 9, KNC: 12), with label dispensing errors, wrong medication, and wrong dosage as the leading causes. Despite the establishment of a Hospital Patient Safety Team (KPRS), no systematic assessment of patient safety culture had previously been conducted, leaving a critical gap in understanding the organizational factors underlying these incidents. This study aimed to determine factors influencing patient safety culture as perceived by nurses at Hospital X. A quantitative cross-sectional design was employed, with 82 inpatient nurses selected via simple random sampling. Data were collected using a validated AHRQ-based questionnaire and analyzed using Chi-square and Fisher's Exact tests. The average positive response to patient safety culture was 81.5%. The highest-scoring dimensions were cooperation within the unit (90.2%), open communication (84.1%), and staffing (84.1%), while cooperation between units (74.4%) and error feedback (76.8%) scored lowest. All 12 dimensions showed significant associations with patient safety culture (p < 0.05). The strongest associations were found in open communication (p = 0.001; OR = 18.9), error feedback (p = 0.001; OR = 27.5), staffing (p = 0.001; OR = 17.1), and patient transition (p = 0.001; OR = 15.2). These findings indicate that inter-unit coordination and structured error feedback are the most critical intervention targets. Hospital management should prioritize implementing a non-punitive incident reporting system, standardized SBAR-based handover protocols, and integrating patient safety competencies into regular clinical supervision to meaningfully reduce preventable incidents.
References
World Health Organization. Patient Safety. BMJ Quality and Safety. 2019 Oct. doi:10.1136/bmjqs-2012-001748 PubMed PMID: 24048616.
World Health Organization. Global Action on Patient Safety. BMJ Quality and Safety. 2019 Oct. doi:10.1136/bmjqs-2012-001748 PubMed PMID: 24048616.
World Health Organization. Global Burden of Preventable Medication-Related Harm in Health Care : A Systematic Review. Geneva: World Health Organization; 2023.
Vikan M, Haugen AS, Bjørnnes AK, Valeberg BT, Deilkås ECT, Danielsen SO. The association between patient safety culture and adverse events – a scoping review. BMC Health Serv Res. 2023 Dec 1;23(1):1–27. doi:10.1186/s12913-023-09332-8 PubMed PMID: 36991426.
Agency for Healthcare Research and Quality. AHRQ Hospital Survey on Patient Safety Culture Comparative Database [Internet]. United State; 2018 Mar. Available from: www.ahrq.gov
Mrayyan MT. Predictors and outcomes of patient safety culture: a cross-sectional comparative study. BMJ Open Qual. 2022 Jul 1;11(3):1–12. doi:10.1136/bmjoq-2022-001889 PubMed PMID: 35798501.
Buhari B, Machmud R, Dorisnita D. Factors associated with patient safety implementation based on safety attitudes questionnaire in accredited hospital Jambi City Indonesia. Riset Informasi Kesehatan. 2019 Dec 30;8(2):157. doi:10.30644/rik.v8i2.300
Pertiwi RA, Sjaaf AC, Andriani H, Oktamianti P. Peningkatan Pelaporan Insiden Keselamatan Pasien dengan Digitalisasi di Rumah Sakit Pemerintah di Jakarta. Syntax Literate: Jurnal Ilmiah Indonesia. 2024 Sep;9(9):5156–63.
Alshammari AS, Aldhuwayhi TZ, Alibrahim NO, Almhna SM, Al Shehadeh ZA, Altaymani SA, et al. Assessment of Patient Safety Culture Among Nurses Working at Tertiary Care Hospitals in Aljouf Region, Saudi Arabia. Cureus. 2024 Apr 17;16(4):1–12. doi:10.7759/cureus.58429
Hamed MMM, Konstantinidis S. Barriers to Incident Reporting among Nurses: A Qualitative Systematic Review. West J Nurs Res. 2022 May 17;44(5):506–23. doi:10.1177/0193945921999449
Althobaiti FM. The effects of leadership on patient safety culture in health care: a systematic review. BMC Nurs. 2026 Jan 8;25:1–20. doi:10.1186/s12912-025-04263-7 PubMed PMID: 41507881.
Oweidat I, Al-Mugheed K, Alsenany SA, Abdelaliem SMF, Alzoubi MM. Awareness of reporting practices and barriers to incident reporting among nurses. BMC Nurs. 2023 Dec 1;22(1):1–10. doi:10.1186/s12912-023-01376-9
Nugraha A, Laili Rahmiyati A, Yuliaty F. Analysis Of Patient Safety Culture On Patient Satisfaction And Its Implications On The Quality Of Healthcare Services. Hearty: Jurnal Kesehatan Masyarakat [Internet]. 2026 Jun;14(3):917–27. Available from: https://ejournal.uika-bogor.ac.id/index.php/Hearty/issue/archive
Makiah M, Noermijati N, Hadiwidjojo D, Moko W. Clinical leadership and knowledge management: Essential role in patient safety culture? Uncertain Supply Chain Management. 2023 Jun 1;11(3):1295–304. doi:10.5267/j.uscm.2023.3.018
Bahri S, Fitriani AD, Jamaluddin J. An Overview of Patient Safety Culture with the AHRQ. Journal La Medihealtico. 2023 Feb 15;3(6):493–506. doi:10.37899/journallamedihealtico.v3i6.766
Li W, Peng C, Gu L, Fu W, Tang F. Patient safety culture assessment in five public hospitals of Sichuan Province: a cross-sectional study with HSOPSC 2.0. Front Public Health. 2025 Dec 15;13:1–14. doi:10.3389/fpubh.2025.1703929 PubMed PMID: 41473703.
Hafezi A, Babaii A, Aghaie B, Abbasinia M. The relationship between patient safety culture and patient safety competency with adverse events: a multicenter cross-sectional study. BMC Nurs. 2022 Nov 1;21(1):292. doi:10.1186/s12912-022-01076-w
Badu MG. Hubungan Kohesivitas dengan Kerjasama Tim dalam Budaya Keselamatan Pasien di Ruang Rawat Inap RSD Kalabahi. Open Access Jakarta Journal of Health Sciences. 2023 Jun 2;2(5):726–32. doi:10.53801/oajjhs.v2i5.141
Astuti A, Painringi SA, Kadir AR. Pengaruh Elemen People Pada Knowledge Management Terhadap Budaya Keselamatan Pasien di RSUD A.M Parikesit Tenggarong. Jurnal Kesehatan Masyarakat … [Internet]. 2019 Mar 17;1(2):178–85. Available from: https://journal.unhas.ac.id/index.php/jkmmunhas/article/view/8712
Hartawan A, Fachrin SA, Arman. Kerjasama Dalam Unit dan Keterbukaan Komunikasi terhadap Persepsi Pelaporan Kesalahan Medis oleh Tenaga Kesehatan di RSUD Bantaeng. Window of Nursing Journal. 2020 Dec;01(02):73–86. doi:https://doi.org/10.33096/won.v1i2.251
Wijaya MI. Exploring the relationship between patient safety culture and the full-range leadership theory in primary care settings: a conceptual analysis. Leadership in Health Services. 2024 Sep 30;37(4):499–510. doi:10.1108/LHS-04-2024-0037
Specchia ML, Cozzolino MR, Carini E, Di Pilla A, Galletti C, Ricciardi W, et al. Leadership Styles and Nurses’ Job Satisfaction. Results of a Systematic Review. Int J Environ Res Public Health. 2021 Feb 6;18(4):1552. doi:10.3390/ijerph18041552
Heriyati H, Al Hijrah MF, Masniati M. Budaya Keselamatan Pasien Rumah Sakit Umum Daerah Majene. Window of Health : Jurnal Kesehatan. 2019 Jul 25;194–205. doi:10.33096/woh.v2i3.588
Ambarwati Lestari E, Devi Fitriani A, Jamaluddin. Analisis Faktor Penyebab Rendahnya Pelaporan Insiden Keselamatan Pasien di Rawat Inap RSU Mitra Medika Bandar Klippa Tahun 2021. Journal of Healthcare Technology and Medicine. 2021 Oct;7(2):891–915. doi:https://doi.org/10.33143/jhtm.v7i2.1596
Halawa A, Setiawan S, Syam B. Persepsi Perawat tentang Peran dalam Meningkatkan Keselamatan Pasien. Journal of Telenursing (JOTING). 2021 Apr 5;3(1):73–84. doi:10.31539/joting.v3i1.2096
Hardy IPDK, Yudha NLGAN, Sarikumpul NN. Implementasi Budaya Keselamatan Pasien Terhadap Kinerja Pegawai di RSUD Wangaya Kota Denpasar. Jurnal Kesehatan Terpadu. 2020 Oct;4(2):57–63.
Marselina EV, Prayitno H, Ismara KI. Dimensi Budaya Keselamatan Pasien dan Insiden Keselamatan Pasiendi RS X Kota Malang. Jurnal Penelitian Kesehatan Suara Forikes. 2023 Apr;14(2):275–9. doi:http://dx.doi.org/10.33846/sf14208
Wahyuningsih CS, Asih EB, Masitoh R, Rahmawati K. Patient Safety Culture in Hospitals based on Agency for Health Care Research and Quality. Journal of Health Policy and Management. 2024;09(02):197–210. doi:10.26911/thejhpm.2024.09.02.06
Shameela A, Sulistiadi W. The Role of Teamwork in Building Patient Safety Culture at Hospital “X” in South Jakarta, Indonesia. International Journal of Nursing and Health Services (IJNHS). 2024 Feb 20;7(1). doi:10.35654/ijnhs.v7i1.765
Schmutz JB, Meier LL, Manser T. How effective is teamwork really? The relationship between teamwork and performance in healthcare teams: A systematic review and meta-analysis. BMJ Open. 2019 Sep 1;9(9). doi:10.1136/bmjopen-2018-028280 PubMed PMID: 31515415.
Brown K, Danby G, D’Souza N, Deniz C, Lewandowska A, Davidson J, et al. Just culture and restorative just culture in healthcare settings: a scoping review of interventions, activities, factors and outcomes. BMC Health Serv Res. 2026 Dec 1;26(1):1–16. doi:10.1186/s12913-026-14095-z
Fitriyah H, Faridah I, Wibisno A. Pengaruh Budaya Menyalahkan (Blaming Culture) Terhadap Tingkat Melapor Insiden Keselamatan Pasien. Jurnal Ilmiah Kedokteran dan Kesehatan. 2023 Jan;2(1):1–6. doi:https://doi.org/10.26911/thejhpm.2024.09.02.06
Müller M, Jürgens J, Redaèlli M, Klingberg K, Hautz WE, Stock S. Impact of the communication and patient hand-off tool SBAR on patient safety: A systematic review. BMJ Open. 2018 Aug 1;8(8):1. doi:10.1136/bmjopen-2018-022202 PubMed PMID: 30139905.
Dhamanti I, Leggat S, Barraclough S, Rachman T. Factors contributing to under-reporting of patient safety incidents in Indonesia: leaders’ perspectives. F1000Res. 2022 May 10;10:1–23. doi:10.12688/f1000research.51912.1
Copyright (c) 2026 Muhammad Iqbal, Firmansyah Kholiq Pradana P.H, Vilda Ana Veria Setyawati, Lutfiyah Rizqulloh
This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.
