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All Journal International Journal of Public Health Science (IJPHS) Jurnal Kesehatan Masyarakat Public Health of Indonesia Jurnal Penelitian Pendidikan IPA (JPPIPA) Window of Health : Jurnal Kesehatan Global Health Management Journal Jurnal Kesehatan Ibu dan Anak Unnes Journal of Public Health Open Access Health Scientific Journal Ahmar Metastasis Health Journal (AMHJ) Journal of Health and Nutrition Research Makara Journal of Health Research AMPLITUDO: Journal of Science & Technology Innovation Thrive Health Science Journal MEDICA (International Medical Scientific Journal) Unnes Journal of Public Health Jurnal Info Kesehatan ELECTRON (Journal of Science and Technology) Kesmas: Jurnal Kesehatan Masyarakat Nasional (National Public Health Journal)
Maretalinia, Maretalinia
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Journal : Open Access Health Scientific Journal

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Human Error and Near Misses in Hospital Occupational Safety: A Root Cause Analysis Using HFACS Framework Hizriansyah, Hizriansyah; Maretalinia, Maretalinia
Open Access Health Scientific Journal Vol. 6 No. 2 (2025): August 2025
Publisher : Griya Eka Sejahtera

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55700/oahsj.v6i2.95

Abstract

Background: Occupational health and safety (OHS) at hospitals is at high risk of near-miss events and human error, both of which have an influence on healthcare workers' safety and service quality. Although many hospitals have technical SOPs, problems still occur because the underlying reasons are rarely properly investigated. The Human Factors Analysis and Classification System (HFACS) framework can assist uncover the underlying causes of accidents, however its implementation in Indonesian hospitals is limited.Methods: This study used a qualitative case study methodology and a root cause analysis technique based on HFACS. Data were gathered over a six-month period by reviewing near-miss occurrence reports and conducting in-depth interviews with seven key informants at Patut Patuh Patju Hospital in West Lombok. Thematic analysis was carried out using NVivo, with data triangulation and member verification.Results: A total of 27 near-miss occurrences were discovered, with root cause patterns spanning all four levels of HFACS: risky acts, preconditions for unsafe acts, insufficient supervision, and organizational impacts. SOP breaches, weariness from heavy workloads, inadequate supervision, and an incident reporting culture that did not yet support the program were among the most significant issues.Conclusion: The deployment of HFACS successfully maps the interactions that produce OHS events at all levels in hospitals. These findings highlight the need of transforming the workplace safety culture into a non-punitive learning culture, which is supported by active supervision, continuing training, and work management rules that are more sensitive to tiredness concerns.
Co-Authors Adi Yeremia Mamahit Agastya, I Gusti Ngurah Akbar, Hairil Amaliah, Lili Anita Rahmiwati Ari Nuswantoro Desi Desi, Desi Destiwi, Monita Diary, Dwina Gustia Dimas Sondang Irawan Doni Marisi Sinaga, Doni Marisi Donny Nauphar Dyah Anantalia Widyastari Dyah Suryani Edwin, Vebby Amellia Edwin, Vebby Emilia Eko Budi Santoso Eko Budi Santoso Elvi Juliansyah Farachdiba, Farachdiba Fardhiasih Dwi Astuti Fatmalina Febry Fattah, Rifqi Abdul Fenny Etrawati Fitri Indrawati Fitriani, Arifah Devi Hananto, Andang Adi Fitria Hariyanti, Yunida Hartuti, Eka Putri Hattapradit, Faron Heni Rusmitasari Heri, Mochamad Hizriansyah, Hizriansyah I Wayan Supetran, I Wayan Imma Fatayati Indriyani, Mila Melinda ISWAHYUDI ISWAHYUDI Jamhari Jamhari Kaseger, Henny Khan, Muhammad Uzair Krisnita Dwi Jayanti, Krisnita Dwi Kurniawan, Febrian Hendra Laila Kamilla Linda Suwarni Linda Triana Linh, Nguyễn Hoàng Thuỳ Macnab, Andrew John Made Dian Shanti Kusuma Maemunah Manisha, Manisha Marice Marice Melisa Frisilia, Melisa Moehas, Puput Kusumawardani Mohamad Sadli Munazar Munazar Musparlin Halid Ni Wayan Kesari Dharmapatni Nilasari, Nilasari Niluh Desy Purnamasari Noor, Hafizh Muhammad Norsaputra, Ary Nurhadiah, Nurhadiah Nurmalita Sari, Marlynda Happy Oktaviyani, Prisilia Pancanugraha, Andi Pangaribuan, Maslan Pratama, Mahendrawan Nugraha Aji Pratamasari, Rossy Pratiwi, Ivana Aprilia Prautami, Erike Septa Prayitno, Tommi Purnama Sari, Indah Putra, I Gusti Ngurah Edi Putra, Wahyu Manggala Putri Sabila, Virgina Rahayu, Merda Sri Rahma Hilmawati, Zaida Rahman, Pamuko Aditya Rifky, Mohamed Rostianingsih, Dewi Ruswandi, Indra Sadli, Mohamad Saki, Vernonia Yora Salman Salman Salman Salman Samosir, Ricky Alexander Sari, Ariestya Indah Permata Sari, Marlynda Happy Nurmalita Satria, Ana Sera, Agnescia Clarissa Shidiq, Galih Albarra Siantar, Rupdi Lumban Siregar, Renince Sri Nurcahyati Suharto, Teguh Sujiyatini, Sujiyatini Sukmawati, Ellyzabeth Sunengsih, Eltri Yani Supriatin Supriatin, Supriatin SUROYO, RAZIA BEGUM Suyitno Suyitno Syamsuriansyah, Syamsuriansyah Syopingi, Syopingi Tantrakarnapa, Kraichat Teten Tresnawan Tiara Fatmarizka Vejvisithsakul, Pichpisith Pierre Viniriani, Marina Ayu Wahyuni, Nuniek Tri Wibowo, Canggih Puspo Wiwit Desi Intarti Yanuarti Petrika Yayu Angriani Yeni Yeni Yuliantisari Retnaningsih Yulianto, Aris Yunus, Mohd Yusuf Yusuf