Factors Associated with Primary Healthcare Center Worker’s

Knowledge About Patient Safety: A Cross-Sectional Study in

Buleleng, Bali

Putu Ayu Indrayathi

1,2,3 a

, Luh Putu Sinthya Ulandari

1 b

, Putu Erma Pradnyani

4 c

and Laszlo Robert Kolozsvari

2,3 d

Department of Public Health and Preventive Medicine, Faculty of Medicine, Udayana University Bali, Indonesia

Doctoral School of Health Science, University of Debrecen, Hungary

Department of Family Medicine and Occupational Health, University of Debrecen, Hungary

Health Polytechnic Kartini Bali, Bali, Indonesia

Keywords:

Patient Safety, Primary Healthcare Center, Quality, Knowledge.

Abstract: Patient safety improvement is primarily discussed around hospital settings. Since primary healthcare center

is the gatekeeper to the health system in Indonesia, it has the premise of resolving community health problems.

Little research was given attention on patient safety implementation at the primary care level. The study,

therefore, aimed to determine factors related to health workers' knowledge about patient safety in primary

healthcare centers of Bali province. This current study used a cross-sectional design. It was conducted from

April to May 2021. The research population was all health workers who worked in 20 primary health centers

of Buleleng regency, Bali. This study selected 699 respondents as samples that participated in the survey. The

survey was a self-administered questionnaire consisting of closed questions. Multiple linear regression was

then conducted to determine factors associated with health workers’ knowledge level regarding patient safety.

Based on the multiple linear regression test, education level and exposure to information contribute to

understanding patient safety (p < 0.01). Primary healthcare workers in Bali have sufficient knowledge

regarding patient safety. However, some aspects need improvement. Effective communication and

understanding of dangerous medication remain major challenges in patient safety practices. Thus, the

Buleleng District Health Office must provide socialization, training, and policy on patient safety standards.

1 INTRODUCTION

Patient safety is crucial for establishing health care

quality. Although patient safety incidents are

reported low, millions of patients worldwide are

likely to suffer disabilities, injuries, or death every

year due to unsafe medical care. Most health care

takes place at the primary level. It is important for

primary healthcare centers to provide the community

with safe, sustainable and universally accessible care.

Primary healthcare center has been envisioned to be

an integral part of the health system and a cornerstone

in communities' social and economic growth since

the late seventies according to the Alma Ata

https://orcid.org/0000-0001-7639-215X

https://orcid.org/0000-0002-3473-6046

https://orcid.org/0000-0001-6827-2764

https://orcid.org/ 0000-0001-9426-0898

Declaration (Alameddine et al., 2015). Primary

healthcare centers are the first contact that the

community can reach out. However, referral to

higher health facilities such as hospital makes

primary healthcare centers underestimated (Sheik et

al., 2013). Some studies have found errors in primary

healthcare centers related to their organization,

notification of doctors, communication, and staffing

(Sheikh, et al., 2013; Marchon & Junior, 2014).

These problems can lead to negative consequences in

patient services (Marchon & Junior,2014; Makeham

et al., 2015; Singh et al., 2017)

Primary healthcare center is widely available in

Indonesia. Maintaining patient safety is important

Indrayathi, P., Ulandari, L., Pradnyani, P. and Kolozsvari, L.

Factors Associated with Primary Healthcare Center Worker’s Knowledge About Patient Safety: A Cross-Sectional Study in Buleleng, Bali.

DOI: 10.5220/0012016500003576

In Proceedings of the 2nd Bali Biennial International Conference on Health Sciences (Bali BICHS 2022), pages 96-100

ISBN: 978-989-758-625-5

 2023 by SCITEPRESS – Science and Technology Publications, Lda. Under CC license (CC BY-NC-ND 4.0)

according to the Regulation of the Indonesian

Minister of Health Regulation No. 75 of 2014

concerning Primary Healthcare Center and No. 11

2017 concerning Patient Safety. Regulations about

these topics are also addressed in accreditation

standards for primary healthcare centers, doctor

practice/clinics, and other first level health service

facilities (Indonesian Ministry of Health, 2017).

Patient safety in primary healthcare centers is not as

managed as at hospitals. There were no modules or

guidelines available. Comparing the number of

health care providers, Indonesia had 2,925 hospitals

and 10,205 primary healthcare centers in 2020

(Ministry of Health, 2021). That primary healthcare

centers are more spread than hospitals suggests that

patient safety must also be prioritized for primary

care. Most primary healthcare workers did not

understand the concept and definition of patient

safety (Satrya, Susilowati, and Sunukanto, 2018).

Primary healthcare center is the gateway to the health

system; therefore, health workers need to have

adequate knowledge about patient safety to minimize

the incidence of adverse events. With proper

management, primary healthcare centers can help

secondary healthcare providers such as hospitals to

solve various adverse events. Thus, this study aimed

to measure and determine factors related to health

workers’ knowledge about patient safety.

2 METHODS

2.1 Study Design and Setting

This study used a cross-sectional design to identify

factors related to health workers’ knowledge about

patient safety. This study was conducted from April

to May 2021. Data were collected using a self-

administered questionnaire consisting of closed

questions. The questions had positive and negative

statements. This study used a total sampling

technique to select 699 samples from 20 primary

healthcare centers in Buleleng regency (Department

of Health, 2020). The eligibility criteria of the

samples were active health workers who were

registered in the Buleleng Regency Health Office and

willing to participate in this study.

2.2 Study Variables

Twenty questions related to patient safety were listed

in the questionnaire. Items on knowledge about

patient safety were designed based on the guidelines

from the Regulation of the Indonesian Minister of

Health No.11 of 2017 (Indonesian Ministry of

Health, 2017). The dependent variable of this study

was knowledge about patient safety, while the

independent variables were socio-demographic

characteristics of the staff (age, gender, education

level, and length of work), exposure to information

about patient safety, participation in patient safety

training, and the existence of supporting documents.

The supporting documents reviewed were the decree

letter of the quality and patient safety team, patient

safety incident reporting procedures, incident

reports, monitoring, evaluation schedule, and review

papers. The primary healthcare centers were

considered complete if they had at least 4 (four)

records. Gender category was divided into male and

female, and education category was grouped into

high school, diploma, and bachelor/postgraduate.

The last variable was the history of providing

information and training that was grouped into ever

and never. The questionnaire was confirmed valid

and reliable based on the Pearson correlation

statistical test (r count > r table or in-cor > 0.3) and

Cronbach alpha (>0.6). Statement numbers 3, 10, 13,

19, and 20 were negative statements. Answers were

scored one if they were correct and 0 if it was wrong.

Due to the pandemic COVID 19, data collection was

strictly carried out according to health protocols.

2.3 Statistical Analysis

All data were then edited and cleaned for analysis.

Descriptive statistics were used to obtain variable

distributions (i.e., frequencies, percentages, means,

and standard deviations). In addition, bivariate linear

regression test was employed to determine

associations between independent and dependent

variables; candidate variables were nominated with

p-values of < 0.25. A multiple linear regression test

was performed to determine which independent

variables were associated with the dependent

variable. Results would be considered significant if

p-values were < 0.05. All data analyses were

conducted using Stata 14.0.

2.4 Ethical Approval

This study was granted an ethical approval from the

Ethics Commission, Faculty of Medicine, Udayana

University under the Ethics License Number:

2021.01.1.0381. All respondents’ data were

anonymous to maintain confidentiality. All

respondents gave their consent to participate prior to

the survey.

Factors Associated with Primary Healthcare Center Worker’s Knowledge About Patient Safety: A Cross-Sectional Study in Buleleng, Bali

3 RESULTS

Table 1 shows the participants’ socio-demographic

characteristics. The median age group is almost of 41

years. Most respondents were female (72.8%), had a

diploma degree, and had worked for more than 14

years. Nearly all respondents claimed to have

received information about patient safety, mostly

from the mass media. Most of the respondents

(83.3%) never attended training on patient safety, and

they (86%) mostly had complete supporting

documents at primary healthcare centers.

Table 1: Respondents’ socio-demographic characteristics.

Socio-demographic

Characteristics

Frequency

(N)

Proportion

(%)

Age

(Median ±IQR)

(41±18)

Gender

Male 190 27.2

Female 509 72.8

Latest Education

≤ High School

87 12.4

Diploma

435 62.2

University

177

25.4

Working Period

(Median ±IQR)

Having heard information about patient safety

Ever 33 4.7

Never 666 95.3

Patient safety training

Never 583 83.3

Ever 117 16.7

Availability of supporting documents

Not complete 98 14

Complete 601 86

The minimal score in level of knowledge about

patient safety is 3 (three), and the maximal score is

20. With normally distributed data about knowledge,

the median and interquartile range (Median ±IQR) is

17 ±3. Table 2 gives the details of the respondents'

answers on patient safety. Many respondents lack

knowledge about effective communication and types

of dangerous drugs.

Table 2: Statement items regarding patient safety

knowledge.

No Statements Answer (%)

True False

1 Patient safety is a system that makes

patient care safer.

687

(98.3)

(1.7)

2 Patient safety is an important thing to

do and an obligation to the health

service

691

(98.9)

(1.1)

3 A patient safety incident is any

intentional event and condition that

438

(62.7)

261

(37.3)

results in or potentially results in a

reventable injury to the patient.

4 An unexpected event is an event that

causes injury to the patient due

595

(85.1)

104

(14.9)

5 Patients are identified using at least two

identities: the patient's name and date of

irth.

542

(77.5)

157

(22.5)

6 Identification of the patient is made

before the administration of drugs,

loo

, or blood products.

603

(86.3)

(13.7)

7 In the clinical examination, the patient

is identified before treatment and

action.

675

(96.6)

(3.4)

8 The purpose of patient identification is

to prevent errors in drug administration

and action.

681

(97.4)

(2.6)

9 Effective communication is carried out

etween health workers.

497

(71.1)

202

(28.9)

10 Effective communication that is timely,

accurate, clear, and easily understood

by the recipient will add to the action

error.

244

(34.9)

455

(65.1)

11 Drugs that include the drug NORUM

(the name and similar appearance)

should be re-spelle

y the officer.

649

(92.8)

(7.2)

12 Effective communication can improve

atient safety.

677

(96.9)

(3.1)

13 Predatory drugs are at low risk of

causing unwanted impacts.

252

(36.1)

447

(63.9)

14 Predatory drugs are drugs that look

similar or similar to speech.

646

(92.4)

(7.6)

15 Electrolyte concentrates are not in the

patient's care unit unless clinically

needed and taken action.

417

(59.7)

282

(40.3)

16 Electrolyte concentrate stored in the

patient's care unit should be clearly

labeled and stored in a tightly restricted

area.

589

(84.3)

110

(15.7)

17 To reduce the risk of infection, wash

your hands fo

five moments.

628

(89.8)

(10.2)

18 Excellent and proper handwashing is

done with six steps of handwashing.

669

(95.7)

(4.3)

19 The use of gloves leads to the absence

of the need to wash hands fi

st.

130

(18.6)

569

(81.4)

20 Hand washing is not one of the

measures to reduce the risk of infection.

145

(20.7)

554

(79.3)

Table 3 shows the results from multivariate analysis

of the multiple linear regression test; factors

associated with the respondents' knowledge about

patient safety are gender, education, exposure to

information about patient safety, and the availability

of supporting documents (p < 0.05). Male

respondents have better knowledge of patient safety

than female respondents (31%). Education level and

exposure to information contribute to the

understanding of patient safety.

Table 3: Relationship between respondents' demographic

characteristics and knowledge level.

Variable Bivariate Analysis Multivariate Analysis

95% CI P -

values

95% CI P -values

B Lowe

Uppe

B Lowe

Uppe

Age -0.01 -0.03 0.01 0.125 0.01 -0.04 0.05 0.822

Gender

Male Reff . . . . . . .

Female 0.69 0.28 1.10 0.001* 0.24 -0.19 0.68 0.279

Latest Education

≤High

School

Reff

Diploma 1.73 1.18 2.29 0.000* 1.23 0.65 1.83 0.000*

Universit

1.97 1.34 2.59 0.000* 1.49 0.87 2.11 0.000*

Working

Period

-0.01 -0.03 0.01 0.162 -0.01 -0.05 0.04 0.733

Having heard information about patient safety

Neve

Reff . . . . . . .

Eve

2.84 2.00 3.69 0.000* 2.13 1.27 2.98 0.000*

Training history

Eve

0.06 -0.44 0.55 0.815

Neve

Reff . . .

Availability of supporting documents

Complete 1.22 0.69 1.74 0.000* 0.99 0.48 1.50 0.000*

Not

Complete

Reff . . .

Bali BICHS 2022 - The Bali Biennial International Conference on Health Sciences

4 DISCUSSION

Patient safety remains a challenge in primary

healthcare centers in many developing countries.

Patient safety is a program that aims to improve the

service process to avoid unwanted events through a

comprehensive service plan (Ministry of Health,

2017). Therefore, healthcare workers in primary

healthcare centers must have background knowledge

about patient safety. Since primary healthcare centers

are considered the front line of public health, having

sufficient knowledge may help health workers

prevent adverse events that may disadvantage

patients (Gobashi et.al 2014).

This study found that most participants had good

knowledge about patient safety. However, some

aspects need improvement to minimize preventable

errors in health services. Effective communication

among healthcare workers remains an issue. Factors

that contributed most to adverse events were failures

in communication and management either in

professionals or between professionals and patients

(Marchon & Junior, 2014). Effective communication

between health workers needs to improve because

communication errors may lead to poor patient

safety. This finding aligns with a study by Daker-

White et al., suggesting that significant safety

concerns are failures to communicate or transfer

medical information between health workers.

Communication is fundamental to safety (Daker-

White et. al,2015).

Communication errors may act as a contributing

factor to incidents. This is in line with the Joint

Commission International argument that

communication between staff could improve the

quality of services and the incidence of unexpected

events by informing important information related to

patients’ condition to the right person on time (Joint

Commission International, 2014). Effective, timely,

accurate, clear, and easy-to-understand

communication will reduce errors in action.

Generally, openness to communication is a struggle

in most developing countries, leading to a punitive

and blaming culture in cases of error or near-miss

reporting. As a result, communication sometimes

becomes a significant obstacle to improving the

quality and safety of care at primary healthcare

centers (Marchon & Junior, 2014; Lawalati et al.,

2014). This study also found that health workers'

knowledge about high-risk drugs remained low.

Meanwhile, the most common errors in primary care

involved medication errors and diagnostic errors

(Makeham et .al,2015). Sufficient knowledge about

high-risk drugs is essential for community health

workers to minimize the unwanted effects of

medications. High-risk drugs must be analyzed

carefully to avoid mistakes. According to Aprilia

(2011), the administration of drugs to patients

requires good knowledge and responsibility to ensure

appropriate prescription. Medication errors can result

in severe patient injuries or deaths, yet

preventable. Prescription errors that occur in primary

healthcare centers is one form of medication errors.

Prescriptions errors may include wrong medication,

drug-drug interactions, and inaccurate written

prescription orders (Smith et al., 2017). Errors in

medication management in primary healthcare

centers are significant threats to patient safety.

Based on multivariate analysis, this study found

that education level and exposure to information

contribute to understanding patient safety. According

to Pratiwi (2019), education level proportionally

aligns with knowledge or ability to absorb

information. Education level, therefore, can be a

criterion for future health workers to serve patients

better (Pratiwi,2019). Previous study also explained

that good knowledge could lead to skill development,

especially competencies in patient safety. Receiving

information increases knowledge (Rahmaningrum,

2017), which is not merely obtained from formal

education but also non-formal education such as

seminars or training and mass media such as the

internet and books (Arini et al., 2014). Goslin (2013)

argues that one can seek knowledge, skills, values,

and norms to implement at their workplace.

Therefore, it is necessary to increase staff’s

knowledge related to information and policy support

on patient safety. Similar arguments explained by Al-

Khaldi (2013) explain that health workers who did

not participate in any training on patient safety had

less knowledge about "medical errors" and its causes.

Continuous professional development programs are

required to provide health workers with information

about common medical errors and patient safety (Al-

Khadi, 2013).

4.1 Limitations

This current study posed some limitations. First, the

use of a cross-sectional design may lead to

differences between factors that influence patient

safety in other countries. Also, questions to a binary

right-wrong create a potential response bias from the

participants. Nevertheless, research findings may

inform and assist primary healthcare centers and

health stakeholders to formulate interventions on

improving patient safety. Continuous education for

Factors Associated with Primary Healthcare Center Worker’s Knowledge About Patient Safety: A Cross-Sectional Study in Buleleng, Bali

the health workers in Puskesmas on patient safety is

required.

5 CONCLUSION

Generally, primary healthcare centers in Buleleng,

Bali have health workers who had sufficient

knowledge regarding patient safety. The level of

education is predominantly associated with their

knowledge about patient safety. However, effective

communication and understanding of dangerous

medication are two aspects that warrant analysis to

find a better intervention. Providing information and

sustainable training to all staff, not just medical staff,

will increase staff knowledge about patient safety.

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