Inge Dhamanti, Sandra Leggat, Simon Barraclough, Benny Tjahjono

Incident reporting is widely acknowledged as one of the ways of improving patient safety and has been implemented in Indonesia for more than ten years. However, there was no significant increase in the number of reported incidents nationally. The study described in this paper aimed at assessing the extent to which Indonesia's patient safety incident reporting system has adhered to the World Health Organization (WHO) characteristics for successful reporting. We interviewed officials from 16 organizations at national, provincial and district or city levels in Indonesia. We reviewed several policies, guidelines and regulations pertinent to incident reporting in Indonesia and examined whether the WHO characteristics were covered in these documents. We used NVivo version 9 to manage the interview data and applied thematic analysis to organize our findings. Our study found that there was an increased need for a non-punitive system, confidentiality, expert-analysis and timeliness of reporting, system-orientation and responsiveness. The existing guidelines, policies and regulations in Indonesia, to a large extent, have not satisfied all the required WHO characteristics of incident reporting. Furthermore, awareness and understanding of the reporting system amongst officials at almost all levels were lacking. Despite being implemented for more than a decade, Indonesia's patient safety incident reporting system has not fully adhered to the WHO guidelines. There is a pressing need for the Indonesian Government to improve the system, by putting specific regulations and by creating a robust infrastructure at all levels to support the incident reporting.