STUDY PHENOMENOLOGY: NURSES PERCEPTIONS OF PATIENT SAFETY GOALS IMPLEMENTATION MEASURES IN HOSPITAL X 2016

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1 STUDY PHENOMENOLOGY: NURSES PERCEPTIONS OF PATIENT SAFETY GOALS IMPLEMENTATION MEASURES IN HOSPITAL X Indrayadi, 2 Achir Yani Syuhaimi Hamid, 3 M. Syafwani 1,3 Universitas Muhammadiyah Banjarmasin, Banjarmasin, Kalimantan Indonesia 2 Universitas Indonesia, Depok, West Java Indonesia, ketikindrayadi@gmail.com ABSTRACT Patient safety is an important issue. The hospital shall be obliged to implement the patient safety culture. Assessment of a patient safety interventions is important to know the application of patient safety. The application of six target patient safety carried out by nurses so that assessment of nurses is the important information early to start a repair. The purpose of obtaining an overview regarding the perception of nurses about patient safety goals implementation efforts at the hospital. The method of this research is a qualitative research phenomenology approach to data collection methods, through indepth interview which features interviews and informed consent guidelines. The total sample of six nurses were taken with how purposive sampling criteria already has attended training or dissemination of patient safety goals. The research found six namely theme 1 focused on the comfort and safety of the patient and the consequences for the hospital. Theme 2 i.e. the efforts of nurses in the implementation of patient safety goals. Theme 3 is a constraint in the implementation of patient safety goals. Theme 4 is how nurses address the constraints in the implementation of patient safety goals. Theme 5 is the necessary support in the implementation of patient safety goals. Theme 6 is nursing hopes in the implementation of patient safety goals. Conclusion: steps to implement patient safety goals. Step One creates organizational systems such as managerial role in the application of patient safety system, facility improvement and financial. The second step is the clarity of the reporting system, nurse care and teamwork. The third stage of patient safety implementation with maximum results seen from the increase of patient satisfaction, nurse satisfaction, improvement of hospital image and financial for hospital and health service provider. Keywords: Perception of nurses, patient safety I. Introduction A hospital has essential role in society life especially for health. A hospital is a very complex place with hundreds medicines, tests and procedures, a lot of equipments and technology, various profession which give patient cares 24 hours (Health Dept, 2008). These characteristics makes the hospital needs to change to reduce the risk of error. Basically a health care ia also an effort to save the patient and for each health care measure given to the patient should give positive effects and should not give detriment to the patient. A hospital in running its function as a modern health care facility reveres patient safety principle as fundamental, as Hippocrates states Primum non nocere which means health care will not injure the patient.

2 Undang-undang RI No 36 Tahun 2009 about health clearly states that hospitals must give priority to patient safety above all. The assessment of a patient safety is an important intervention to knowing the runs of intervention and can give advantages to inform earlier so that we can fix something. Almost all the six patient safety goals measures implementation is managed by nurses. This is the same as the opinion of Schubert et al, (2009); Teng et al, (2012) that nusing resources in essential for patient safety. Based on the explanation above nurses perception becomes the key factor to assess the concept of patient safety works or not. Method In this study, the researcher wants to learn nurses perception on objective implementation of patient safety efforts by using qualitative research design with phenomenology approach involving six participants. This research uses in-depth interview. The interview is done informally, by using interview guidelines, yet the process is fully based on spontaneous and natural improved questions. The media for this research are recording and field notes. Data analysis process uses seven steps of Colaizzi (1978, Sanders, 2003; Speziale & Carpenter, 2007; Morrow,et al 2015) Results The characteristics of the participants The participants are the nures of rwat inap room at X hospital. The total number is six nurses; two males and four females, with the youngest one 26 years old. Theme 1 Focus on the convenience and safety needs and consequences of the hospital Sub-theme the consequences of hospital The hospital which is not implementing patient safety or yet, will surely get the consequences. As stated by such The hospital is responsible for every incident. Even for a loss ones. The image of the hospital could be bad. (P2), the safety we provide could be a guarantee and makes the hospital trusted by the patient. (P5) Sub-theme a rights to be served A patient s basic rights is receive a service given by the hospital without any differences. As stated by such the patient s rights, he or she has a right to get the care by the hospital (P4), the patient surely wants to take the rights to be served (P6)" Sub-theme the needs of convenience and safety During the time the patient in the hospital, he or she is fully under the hospital responsibility for having convenience and safety. As stated by following "if we give a quality, we make sure the patient will be safe" (P1), "the patient s safety is considered as important in our service."(p2), "the six SKP affect the patient s convenience. (P3)"they have rights to be saved((p4), of course the patient wants the importance of convenience and safety first (P5), the safety in guaranteed all over (P6). Theme 2 the nurses efforts to implement patient safety goals Sub-theme Managing Patient identification Make sure the patient is right 102

3 To make sure the patient is right is a way to reduce errors which endanger the patient. As stated by the following "before we take a measure we ask the patient about his or her name while checking the patients identity(id) bracelet "(P1), "so, every time we tke a measure, we check the bracelet "(P2), "each time we take a measure, we will identify the patient,"(p4), "when the patient came, we check it, so we will know if it is right or not "(P5), Recheck the patient Patient identification is an instrument to make sure the right individuals to get the health care. As stated by the following patient identification. If the patient is male, he wears blue bracelet, for females, she wears pink bracelet (P2), "when we hand over the patient, we check if the patient is match with the bracelet "(P5), "we always verify the identity, we check them each time we take a measure "(P6) Sub-theme Managing effective communication Report documentation A report is documented to prove that the service given is right and well done. Some participants stated as follow: "if the patient is in critical state, we directly take Sbar and we documenting it "(P1), "for Tbak sytem, what we take note what the doctor advised, we write the date, the time and the notes. We re-read to make it sure. Tomorrow morning we ask for the doctors signature and stamps to verify the last night s advice.(p3), "the patient s condition is written in the Sbar note (P4)", "in Tbak system, write, read and confirm, if the patient is consulted we take note the advice that given, we repeat it, and so we validate it to the doctor that give his signature "(P6) Reporting orally Speaking is a good way to report amongst health care giver. As stated by following "then we hold TBAK with the doctor "(P1), "we often give SBAR each time we consult the patients to the doctor for instance when we have emergency calls in the ward "(P2), "every consultation to the doctor we deliver it to the patients by using SBAR system "(P3), "there are things that need to be reported by health care givers "(P4),"when the nurses are at the room they must hand over the patient by using SBAR method, explaining what the name is, and what kind of operation will be held then "(P5), "Using SBAR system to utter the patient s condition"(p6) Sub-theme Supervising the usage of high alert medicines Documenting the use of high alert medicines The partisipan told that if they use the medicines they must fill a particular form. This is the quotation of the interview had been done: "for therapy or high alert medicines must be written on medical record, it has a certain form."(p1), "every time we give the high alert medicine, we jot it down""in the patients status registration there is a special sheet for a high alert one ""the registration is given when we give one of the (high alert) medicines "(P2), "if the high alert medicines is used there is a form for it "(P3), "if LASA medicine and high alert ones are used, we will have double check."(p4) 103

4 Recognizing the high alert medicine mark Nurses have a duty of recognizing the marks of high alert medicine. This is the quotation of the interview had been done: "the high alert medicines are red marked "(P1), "so, each time we give patient the medicines with high alert or LASA label"(p3), "red or high alert labelled medicines "(P6), "there is a form or document for high alert medicines, so if they are used of course we will fill out the form "(P6) Sub-theme reducting the errors of surgical patients Using surgery check list The use of check list which is advised is the surgery check list recommended by WHO, it is also used at X hospital. Some participants stated: "we deliver the patient to the operating room using the hand over called sign in "(P1), "using sign in, time out dan sign out"(p5) The witness of site marking preparation The assistance of site marking by nurses. The following is the quotation of the interview: "DPJP Operator (Responsible doctor) who takes the responsibility. The witness of the site marking is the patient and also we, as the assistant nurse."(p1), "the site marking of surgery and anestethic doctor and the surgery of the patient. Beside the doctor, nurses who take care the patient and the patient itself will be marked as well. "(P2), "the responsible doctor (DPJP) is assisted, so we visit the patient a long with the doctor while checing the oter patients,if there is a patient that needs to be marked, the doctor will mark him or her, witnessed by us - the nurses and the patient s family "(P3), "the doctor has a duty to fill the site form of the patient who will be operated, and must go visitation before the surgery and give the mark witnessed by us."(p4), "the doctor who will be operating have a duty to see the patient to mark the site and of course it is assisted by us "(P6) Checking the surgery site Each patient who will be under operation is given a site marking. As stated by a patient identification, the site and what measure will be taken "(P1), "there is a check on surgery site if it is done or not "(P5) Sub-theme Implementing infection control Managing handwash Handwashing is a basic technique to prevent and control infection. The following is the quotations of the interview: "Hand hygiene, which is very familiar right now"(p1), Hand hygiene, we always do it every five washing moments "(P2)"we must be able to do handwashing "(P3), hand hygiene i.e. at the five moments (P4), "five moments and six steps are really needed in hand hygiene "(P5), ""handwashing by five moments and six steps (P6) Separation of medical waste The participants stated the disposal of medical waste and sharp objects are done according to its special trash can. As stated by the "medical waste has been separated. For needles we have special place "(P1), " nurses or doctors here know, for liquids or blood waste we put into the yellow one, drinking 104

5 bottle or IV bottle that did not touch liquids we put into black plastic bag. " (P2), "we separate our medical waste into infectious and non infectious ones"(p3), "from the separated medical waste"(p5), sorting the infectious waste and non infectious ones. Even we have special trash bin for needles"(p6) Education for patient Giving an education about the reduction of the risk of infection has benefits either for the hospital or the patient itself. As stated by a "we have explained Hand hygiene to nurses, patients and the family "(P1), we explained about medical and non medical trash bin to the patient s family. (P2) Sub-theme Managing patient falls observation Managing early observation of patient falls Early observation is done at the emergency room and if it indicates the high risk, we give a yellow bracelet, the following statement is from the interview: "when the patient comes to the emergency room, we observe them for patient falls "(P1), "we manage an early observation for patient falls assessment "(P6) Documenting the observation of patient falls Documentation is a proof that nursing profession has been responsible to guarantee the patient would not fall by documenting the result of the observation. As stated by a "there is a form for the observation. We fill out the form after the patient falls observation "(P2), "the reduction of the risk of the patient falls. Using standard format "(P4) Giving the patient falls bracelet The reduction of falling risk is done by giving falling identification to each patient. It could be bracelet or pin. As stated by following "the patient is given yellow bracelet,"(p2), "we give the patient with falling risk a yellow button "(P3), "the use of yellow button got the nurse be more attentive to the patient "(P5), "we give yellow button to the patient with falling risk (P6) Managing a re-observation If the patient has wore a falling risk mark, the nurse will re-observe them in the nursing room. The following statement is from the interview: "for high falling risk, we observe them 2 hours after entering the room. While the low faling risk, it is usually done one day after "(P2), "has been observed at the emergency room, we will re-observe again at the nursing room "(P3), "managing a patient falls observation "(P5) Theme 3 the obstacle in the implementation of patient safety goals Sub-theme Nurse behavior Carelessness Carelessness is a reason why a nurse rarely works on patient safety. As stated by a "this is new rules we sometimes forget about "(P3), "sometimes it is forgotten. Well, it s humane "(P4) 105

6 A habit that hard to change A habit reflects a nurse behavior, the one that hard to adjust becomes obstacle in implementing patient safety. As stated by a it is hard to change one s habit. (P3), "it is only some nurses do it in this room "(P5) Improper act Human error in implementing onjective patient safety also becomes obstacle for it. As stated by some participants: "the human is human error "(P1), "the falling risk is undergone, but the observation is not really deep "(P2), "effective communication. Sometimes when we are close to the doctor makes we skipped something while delivering the information "(P3) Sub-theme Insufficient Facility The participant stated that they have difficulties about insufficient facility such as identity bracelet and lack of forms. As stated by following "not enough supply of identity bracelet in the nursing room""there is no stock for the bracelet for each room " "talk about facility, we have not enough blank forms "( (P3), "the facilty such as forms or bracelet. We don t have enough " (P6) Out of standard facility The participant stated that the hospital is lack of facility which guarantee the patient safety. As stated by some participants as follow: "for patient falls we should use safety bed. In this hospital, some dept have it, some do not."(p2), "a standard marking is not available for precision of a surgery "(P4), for the facility,i feel it is not enough, because in my room there is no separated entrance line for nurse and patient (P5) Sub-theme the system does not run yet Unclear reporting system The participant also stated that there is unclear reporting system. As told by following "for the report, we know there was an incident here, but that is all. We have not known yet about what action the management will take next."(p1), "we lack of reporting system for patient falls. When there is a patient falls, the report stops at the head of department, no action taken "(P6) No monitoring Monitoring and evaluation is a way to supervise the run of a health care system. As stated by following "monitoring is need, one person or more needs to monitor if the six IPSG is undergone in the room."(p3), "in the afternoon and evening, there is no controlling and evaluation"(p6) No evaluation program Next, the participants also stated that there is no evaluation program. As stated below: "the evaluation should be there to knowing the patient safety runs or not "(P5), "in the afternoon and evening there is no controlling and evaluation, so i think we need some supervision "(P6) 106

7 Theme 4 Nurse ways to overcome the obstacle in implementing patient safety goals Mutual Reminding amongst nurses Reminding each other is beneficial to keep or to control the patient safety. As stated by the participants: if my friends forget, I remind them when we change shift "in the morning when we hand over the duty I remind them again,we remind each other (P1), "we remind each other amongst friends. "(P2), "we often remind each other. So if there is something forgotten, my friends know it and we talk about it "(P3), "we try to remind person to person""we always remind our friends "(P4), "nurses remind each other "(P5), "we, the healthcare official remind each other "(P6) Proposal delivery to the management A proposal to management is a way to give suggestion for management. As stated by the "talking about the facility and advise to the higher, what facilities should be fixed and added."(p2), "give advice to the head of department that there will need to be a supervision "(P3), "I convey it at the meeting and the head of department "(P4), "talk to my friends about who is the good one for supervision s it can run well, and let the head know about the result"(p5), "we suggest the head of department to make a supervision system in the hospital "(P6) Seeking for facilities availability Seeking for facilities availability is an effort made in order to give a good quality service. As told by following "if the bracelets are completely used up, we have to get it from the counter,"(p3), "if the forms is not enough, we usually get it from medical record room"(p6) Advising to improve the insufficient facilities The participants convey the proposal/advice to the higher directly. As stated by the participants: "we suggest a new facility "(P5), "we often suggest about the facility to the head of department, to the higher that it is not sufficient " (P6) Theme 5 support needed in implementing patient safety goals Supports from colleague Colleague is an important factor to give support for keeping patient safety. As stated by the participants: "from colleague. We work together, giving a good quality example "(P1), "the very first support is from colleague "(P6) Supports from the management The powerful support from management is beneficial to give a good quality service that give priority to patient safety. As stated by the participants: "of course the supports from management and from the director"(p1), "the hospital, director, management and the head of department help in case of facilities,"(p2), "but the management should help as well ""the director does not see what happen directly, whether it runs or not""the management just come to the service counter, but we, at the treatment directly in touch. Never for others. "(P3), "at the management, related to material, sometimes it is constrained by printed 107

8 stuff"(p4), "the management party who does not handle the patient, does not support will be useless ""the director, chief of section, chief of sector also must have the same commitment ""when we are working and the higher comes to see us, we will be glad indeed "(P5), "the director, chief of section, chief of sector and head of department must be consistent,"(p6) Theme 6 the nurse expectation in implementing patient safety goals Sub-theme work assessment consequency Reward expectation Reward is an appreciation for works had been done by employees. As stated by following participants: "supporting by financial"(p1)"a good financial in the hospital, a good service, then the financial of the nurse will improve"(p2), "the more patient, the more incomes for the hospital, and perhaps it will influence the nurse"(p3), "the hospital income will improve if the quality is good, we (nurse) will also get improvement "(P4), "the patient is safe, the society trust us, at last we, as nurse will be affected such in financial sector from health care""if we can give a priority to patient safety, with God s will, we can have much more financial improvement,"(p5), "financial improvement, by a good financial will encourage us to work ", "reward is also important, but not only about money, it can be a compliment or award "(P6), Expectation about punishment Punishment appears for employee who made faults and violation. As stated by following participants: what kind of punishment. (P1), " just give the punishment. So if you have no heart, no need to be a nurse.(p5), "a punishment is important to give a lesson to the one who does not work properly "(P6) Sub-theme The quality of service improvement The making of Supervision system A good supervision implementation makes monitoring and evaluation works. As told by following "there is a monitoring and ecaluation system from the management "(P1), "so a good supervision system is made "(P6) The facilities improvement Sufficient facilities surely have a goof effect to a health care. As stated by following "it is supported by any means of facilities " (P1), "supported by improving the means of facilities "(P6) The improvement of service quality A good service quality is reflected by the helath officials behavior while giving care. As stated by following participants: "we expect there will be a quality improvement in giving care "(P4), "do not ever make fatal mistakes to the patient,""if the is a wrong insicion, it will detriment the patient and influences the hospital."(p5) Discussion Focus on the needs of convenience and patient safety and hospital s consecuency. A hospital is demanded to be able to manage their activities by giving priority to the professional responsibility of health care sector. The health care given by medical official is not always give the result that most people expected. For the effect itself, a positive or negative response from the 108

9 clients and patients depends on the running of care service of the hospital. This response makes a picture or image of the hospital appears according to the hospital service user. The second category is a right to be served. Health is one of human basic needs beside clothing, foods and housing. Without healthy life, the human s life has no meaning at all, because if human gets sick he cannot do his daily activities well. Therefore, each sick person keeps trying to get a good medication and treatment so that they can improve their quality of life. The choice of service given by a hospital is an absolute right of the patient to decide which hospital that be able to overcome their complaint, the hospital bills, so it can improve the health level of the patient. The patient has a right to get a treatment which gives priority to safety according to code of ethics, standard of medical treatment, professional and standard of operational procedure, based on what stated in UU RI No about nursing. The third category is the needs of convenience and safety. Safety is the second priority uf human basic needs based on physiological needs in Maslow hierarcy that have to be fulfilled in one s life. The effort of nurse in implementing patient safety goals A name is an inseparable thing with hospital and patient. During the treatment period the nurse has to manage patient identification correctly. International patient safety goals in Dhatt et al, (2011) states a condition that in identification there are at least two patient identification while giving treatment. Medication or health treatment, patient s room number or location can not be used as the identification. The identification that is acknowledged are name, medical record number and date of birth. Managing effective communication, both nurses and cross-profession. Report documentation and oral report are the way participants manage effective communication. According to Sammer, Lykens, Singh, Mains, & Lackan, (2010) one of effective communication is Structured techniques (read-back, SBAR). According to Joffe, et al (2013) indicates SBAR communication technique can improve phone communication between nurses and doctors by using structured and acurate SBAR tools, so the probem can be evaluated and communicated well and clearly, the patient safety can improve. Medicines are identical to pharmacy, but in supervise the use of high alert one, nurses also share the duty of it. In accordance to a research held by Engels and Ciarkowski (2015) that in the process of medicine usage all science field are involved, not only the pharmacists but also the nurses. The participant stated that the red-labelled medicine is the high alert one. It is marked by pharmacists. The Health Ministerial Regulation of Republic of Indonesia number about the Standard of Pharmaceutical Affairs Service at Hospital requires a hospital to develop the policy of medicine management to increase the safety, especially for high alert medications. NPSA (2005) that the agent of surgery or the representatives have the duty to visit before the surgery is carried out at the room where they check the patient s identity and site marking one. The visite by a doctor is assisted by nurse, so the nurse indirectly becomes the site marking witness. Errors at surgery patients can be caused by some factors. One of the ways to reduce the surgical errors is by using standardized surgery check list. A research done by Alex, 109

10 (2009) eight hospitals in eight cities in America indicated that there was a reduction of complication for 11,0% patients to 7,0% after being introduced to surgery check list. The participant also stated that they implement the reduction of risk of infection. In principle, nurse as the medical official will be contacted to the patient s blood or body liquid directly in taking treatment. Therefore, the efforts to keep them safe from infection is really important, i.e. by managing infection control assesment which can be done by healthcare officials to minimize the spreading of infection along with universal precaution. The participants also implement the reduction of patient falls, both since the patient is in the emergency room to the treatment room. In the emergency room, the participant stated that they will manage early assessment for patient falls if the patient is indicated having a high risk of patient falls, then he is given a yellow bracelet, then the nurse will do reassessment in the treatment room. The participant stated that if the patient has a high risk of patient falls, the re-assessment will be done 2 hours after get into treatment room. Both assessment, the early one as well as the second one always be documented. The obstacle in the implementation of patient safety goals Th implementation of patient safety goals has several obstacle. Nurse behavior. Talking about a human s behavior is always unique or special. Means that there are differences amongst them, either for intelligency, talent, attitude, interest, as well as personality. A human behaves or works out to pursue some goals. Some problem related to facilities is also found in this research, as stated by the participants that one reason the nurses did not manage the patient safety is the lack of facilities on identity bracelets and forms for documenting. Wuryanto (2010) said that physical environment like the availability of sufficient working tools, appropriate to what kind of job of the employee can influence themselves. If the facilities are completed, the employees are expected to be able to behave like what the organization wants them do. The last obstacle that happened to nurses is the system which does not work yet, both on monitoring evaluation and reporting system. Monitoring and evaluation activity is aimed to a program which are lasting or had been done before. The monitoring itself is an activity managed by a superior to see and observe the run of organization while it is lasting and assessing the goals achievement. Evaluation is a process to identify problems, collecting and analyzing data, concluding the result, interpreting the result into a formulation of policy, and presenting the information (recommendation) to make a decision based on the truth aspect of the result. The unclarity of the reporting system is an obstacle in implementing patient safety. The world of healthcare is close to blaming culture. Talking about other s mistakes means talking about embarrassing things, related to one s pride. A nurse who involved in the patient safety problem will be labelled a unprofessional nurse, careless, and absent-minded for doing his/her job. The obstacle in the patient safety itself in reporting system is if the problems are reported and discussed, the thing that will be mattered is who did it, not about why that problem happened. 110

11 This third tehem is in accordance to Wood theory: blunt end and sharp end (Ketring, 2006) that the failure of a patient safety or unexpected incident can happen in various factors. The blunt end potrays the organization appearance, policy dan procedure function as a shield and errors prevention. While the nurse is on the sharp end that directly gives the healthcare to the patients. The nurse ways to overcome the obstacle in the implementation of patient safety goals The nurse who often accidentally forget in implementing patient safety goals needs other nurse s role to remind their colleague. The main principle to remnd each other is care or respect to human limitation. Respect to human s limitation is an effective approach in reducting errors. The working realationship amongst nurses is already adjusted in nursing code of ethics. Coveying suggestion to the management, and suggesting a facility improvement are the steps to convey proposals. Communication process in an organization, especially of which related to communication between superior and employee is an important factor in creating an effective organization. Looking for the avaibility of facilities by nurse is a way to overcome the problem. By looking for the avaibility, means that the nurse has been motivated to improve the patient safety in the hospital. The efforts reflected by the nurse indicates that they take a part to guarantee the patient is safe in the hospital. Support that needed in the implementation of patient safety goals An organization in achieving patient safety needs nurses with a high level of loyality, participation, a commitment. Commitment is a thing occurs generally without considering about age, gender, education, position, salary, social status, etc. Management support for implementation of patient safety indicates that a leader and manager have to give examples of the safety value in each of behavior and action in making effort to patient safety and have the safety as the main priority. A good leadership in a social organization like hospital is supported by some important aspects. French anda Raven (1959); Marquis (2010) that the leadership authority is important along with reward power and punishment/coarcive power in using the authority to motivate the employee in working. Vroom s expectancy theory stated that to get someone motivated to do something, he/she must adjust his/her behavior, feeling sure that the adjustment will yield repayment, and the value of the repayment is enough to balance out the change of behavior he has been done (Lunenburg, 2011). This sub-theme is about the improvement of service quality; they are the making of supervision system, the improvement of facilities, and the improvement of service quality. The quality improvement and quality of service is an achievement of what the patient expected and what they got. If it meets the expectation, the patient satisfaction will be improved. Therefore, a hospital have to apply a client-satisfaction oriented management system. Giving care a good quality care service, a nurse always try to meet the patients expectation. Thus, the patient is always satisfied at the service the nurse gives and to get a good quality of nursing care. A good strategy is also important in the improvement of a good quality service and facilities, the quality of service, and the 111

12 making of supervision system in the process to give favor, guidance or instruction, support to someone to finish his job appropriate to the policy and procedure, developing a new skill and giving a broad understanding to do a better job. Conclusion The implementation of patient safety goals can be carried out if there is a team work from all of organization. The first step is making a system of organization such as management s role in the implementation of patient safety system, the improvement of the facilities and financial matter. The second step is the clarity of reporting system and team work. The third step is the implementation of patient safety with a maximum result considered at the improvement of patient satisfaction, nurse satisfaction, the image of the hospital and the financial matter of the hospital and healthcare giver. ) Acknowledgment The preferred spelling of the word acknowledgment in America is without an e after the g. Put sponsor acknowledgments in the unnumbered footnote on the first page. References Ching-I Teng, Yea-Ing Lotus Shyu, Yu-Tzu Dai, May-Kuenwong, Tsung-Lan Chu & Tin- An Chou (2012). Nursing Accreditation System And Patient Safety. Journal Of Nursing Management, 2012, 20, Depkes RI (2004). Ministerial of Health Decree Republic of Indonesia No 1204/Menkes/Sk/X/2004 about The Health Requirement of Hospital Environment. Jakarta : Directorate General of Infectious Disease and Environment Sanitation. Depkes RI (2011). The Ministerial of Health Regulation Republic of Indonesia No about The Hospital s Patient Safety. Jakarta : Health Department Republic of Indonesia. Depkes. (2014). The Ministerial of Health Regulation Republic of Indonesia No about the Standard of Pharmaceutical Service at a Hospital. Jakarta : The Minister of Health Republic of Indonesia. Depkes. RI (2003). The Guidance of Universal Precaution at the Healthcare. Jakarta : Directorate General of Medical Care of Infectious Disease Elimination and Environment Sanitation. Depkes. RI (2006). The National Guidance on Hospital Patient Safety. Jakarta : Health Department Republic of Indonesia. Depkes. RI (2010). The Ministerial of Health Decree Republic of Indonesia No about Hospital Classification. Jakarta : Health Department Republic of Indonesia. Dhatt, G.S., Damir, H.A., Matarelli, S., Krishnan, S., & James, D.M. (2011). Patient safety: patient identification wristband errors. Clinical Chem Laboratory Medicine. Vol.49/No.5 Edy Wuryanto, (2010), Karakteristik Individu Dengan Kepuasan Kerja Perawat RSUD Tugurejo Semarang. Tesis. FIK UI Fred C. Lunenburg (2011). Expectancy Theory Of Motivation: Motivating By Altering Expectations. International Journal Of Management, Business, And Administration Volume 15, Number 1. Haynes, Alex Et al. (2009). A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population. USA. The New England Journal of Medicine, 360:491-9 JoffeE, James P. Turley, Kevin O, Todd R, Craig, W Elmer V. (2013). Evaluation of a Problem - Specific SBAR Tool to Improve After - Hours Nurse - Physician Phone 112

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