ABSTRACT
ABSTRACT: Hospital incident reporting has become one of the most important tools to capture errors, and within incident reporting, learning from errors can be applied and potentially disseminated across staff at all levels. The aim of this study is to investigate the implementation of patient safety incident reporting in Indonesia and to see how public hospitals have implemented the organizational learning arising from incidents. Three public hospitals were purposively selected from three regions in East Java. Hospital directors or managers, patient safety teams, and ward supervisors were interviewed. We applied thematic analysis to analyze the transcripts. Issues found included delays in reporting, unwritten or incomplete reports, lack of staff training, lack of leadership, absence of feedback, and inadequate management supports. Accordingly, we recommend that hospitals conduct and allocate resources for Root Cause Analysis, follow up the corrective actions for an agreed time, conduct further analysis on their data, standardize feedback and dissemination mechanisms, and improve the leadership and organizational factors preventing satisfactory incident reporting.
