Implementing an Electronic Patient Safety Incident Reporting System to Improve Healthcare Quality: A Qualitative Implementation Evaluation
Abstract
Healthcare facilities in Indonesia are required to report patient safety incidents. However, many hospitals continue to face challenges in integrating incident data, conducting systematic analyses, and using incident reports to inform continuous quality improvement initiatives. The Regional General Hospital of Yogyakarta City faces similar challenges because incident reporting and analysis have not been fully integrated within a single system. Therefore, this study aimed to evaluate the implementation of the Patient Safety Incident Reporting (PaSIR) system and explore its contribution to improving incident reporting practices. This study employed a Research and Development (R&D) approach using a User-Centered Design (UCD) methodology. The qualitative evaluation was conducted between January and June 2025. Purposive sampling was used to recruit10 participants, including members of the patient safety team, information technology staff, and public relations personnel. Data were collected through interviews, surveys, document reviews, and focus group discussions (FGDs). Implementation was evaluated using the Consolidated Framework for Implementation Research (CFIR), and data were analyzed thematically using triangulation. Written informed consent was obtained from all participants, and ethical approval was secured prior to the study. Before implementation, incident reporting was fragmented across paper-based forms, Google Forms, and the hospital information system. PaSIR integrated key incident management process, including reporting, validation, root cause analysis, follow-up, and feedback. The findings indicated that PaSIR was user-friendly, responsive to user needs, and provided a more transparent and integrated workflow for incident management. Key factors supporting implementation included staff engagement, regulatory alignment, cross-functional collaboration, and managerial commitment. PaSIR improved the effectiveness of incident reporting, strengthened the patient safety culture, and supported data-driven decision-making. Nevertheless, greater managerial coordination, organizational readiness, user engagement, and ongoing technological integration are needed to ensure sustainable implementation.
Keywords: Patient Safety, Risk Management, User-Centered Design, Quality Improvement, Electronic Health Records
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DOI: http://dx.doi.org/10.30829/contagion.v8i3.30079
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