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Summary Table

Aspect	Detail
Scope	All healthcare facilities (hospitals, puskesmas, clinics) in Indonesia
Governing Body	Komite Nasional Keselamatan Pasien (KNKP) under the Ministry of Health
Types of Incidents	5 categories: KTD, KNC, KTC, KPC, and Sentinel Event
Reporting Obligation	Internal report within 2 x 24 hours or by end of shift
Investigation Method	Simple investigation (Blue/Green grading) or comprehensive Root Cause Analysis (Yellow/Red grading)
Core Principle	Non-punitive, blame-free reporting culture focused on systems improvement
Keywords	"Insiden keselamatan pasien," "grading risiko," "RCA," "investigasi sederhana," "pelaporan insiden internal/eksternal," "budaya keselamatan"

1. Definitions and Classification

A patient safety incident (IKP) is any unintentional event or condition that results in, or has the potential to result in, preventable harm to a patient. Indonesian regulations classify these into five categories, arranged here from the most severe to the most upstream.

Classification Table

Category	Indonesian Term	Definition	Key Feature	Example
Sentinel Event	Kejadian Sentinel	An adverse event resulting in death, permanent injury, or severe temporary injury requiring life-sustaining intervention, unrelated to the natural course of the patient's disease	Triggers immediate comprehensive RCA regardless of grading	A surgeon performs an amputation on the wrong limb. A newborn is switched with another baby and discharged to the wrong family.
KTD (Adverse Event)	Kejadian Tidak Diharapkan	An incident that reaches the patient and causes harm/injury	The error or event did cause patient injury	A patient falls from the hospital bed and sustains a hip fracture. A nurse administers the wrong IV antibiotic, and the patient develops an anaphylactic reaction.
KTC (No-Harm Incident)	Kejadian Tidak Cedera	An incident that reaches the patient but does NOT cause injury	The error reached the patient, yet no harm resulted (by luck or patient resilience)	A patient receives the wrong dose of an oral medication, but the dose difference is clinically insignificant and the patient experiences no adverse effect. A blood transfusion is given with a minor ABO-compatible mismatch, but no transfusion reaction occurs.
KNC (Near Miss)	Kejadian Nyaris Cedera	An incident that could have caused harm but was intercepted before reaching the patient	The error was caught and corrected before patient exposure	A pharmacist prepares a lethal overdose of a drug, but a supervising colleague catches the error and cancels it before the drug is administered. A nurse identifies that the blood bag label does not match the patient's wristband and halts the transfusion before any blood is infused.
KPC (Potential Injury Condition)	Kondisi Potensial Cedera	A condition or situation that carries high potential for injury, but no incident has yet occurred	No event has happened; this is a hazard identification	A ward discovers that two look-alike/sound-alike (LASA) drugs are stored side by side in the same drawer without distinguishing labels. A defibrillator in the emergency unit is found to have an expired battery during routine checks.

2. How to Tell Them Apart

This is the single most tested concept in this topic. The exam will present a scenario and ask you to classify the incident. The decision tree is built on two questions:

Question 1: Did the error/hazard reach the patient?

No, it was caught before exposure, then it is KNC (Near Miss)
No event occurred at all, only a hazardous condition was found, then it is KPC (Potential Injury Condition)
Yes, the patient was exposed, then proceed to Question 2

Question 2: Did the patient sustain injury?

Yes, injury occurred, then it is KTD (Adverse Event) / Sentinel Event according to injury severity
No, the patient was exposed but unharmed, then it is KTC (No-Harm Incident)

The most commonly confused pair is KNC vs. KTC. The discriminator is simple: in KNC, the patient was never exposed to the error. In KTC, the patient was exposed but escaped without injury. If the wrong drug made it into the patient's IV line but caused no clinical effect, that is KTC. If the wrong drug was prepared but swapped out before it entered the IV line, that is KNC.

3. Risk Grading Matrix

After an incident is reported, the next step is grading to determine the level of investigation required. The grading matrix uses two axes: Probability (Likelihood) and Impact (Severity/Consequences).

Probability Scale

Level	Label	Frequency
1	Very Rare (Sangat Jarang)	Could occur in > 5 years
2	Rare (Jarang)	Could occur every 2-5 years
3	Possible (Mungkin)	Could occur every 1-2 years
4	Likely (Sering)	Could occur several times per year
5	Very Likely (Sangat Sering)	Could occur weekly or monthly

Impact / Severity Scale

Level	Label	Description
1	Insignificant	No injury at all
2	Minor	Minor injury; first aid measures sufficient; lengthened stay by 1-3 days
3	Moderate	Moderate injury requiring additional intervention/procedure; lengthened stay by 4-15 days
4	Major	Major injury; loss of function (permanent); lengthened stay > 15 days
5	Catastrophic	Death unrelated to the natural course of illness

Grading Color Bands

Color Band	Risk Level	Investigation Type	Timeline
Blue	Low	Simple investigation by the direct supervisor and unit staff	Maximum 1 week
Green	Moderate	Simple investigation by the direct supervisor and unit staff	Maximum 2 weeks
Yellow	High	Comprehensive investigation / RCA by the Hospital Quality and Patient Safety Committee (Komite PMKP)	Maximum 45 days
Red	Extreme	Comprehensive investigation / RCA by the Hospital Quality and Patient Safety Committee	Maximum 45 days

Sentinel events bypass the grading matrix entirely. Regardless of the calculated color, a sentinel event always triggers a full RCA.

4. Reporting Flow

Step	Action	Who	Timeline / Detail
1. Immediate Response	Address and stabilize the situation (e.g., stop the wrong infusion, manage the patient who fell)	Staff member who discovers or is involved in the incident	Immediately upon discovery
2. Internal Report	File a written internal incident report containing: patient data, chronological narrative, type of incident (KTD/KNC/KTC/KPC), actions taken, patient outcome, and preliminary grading	Same staff member who discovered the incident	Within 2 x 24 hours or by end of shift
3. Grading by the Unit	Assign a preliminary risk grade using the probability-impact matrix (Blue / Green / Yellow / Red)	Direct supervisor or the unit's patient safety officer	Immediately after internal report is received
4. Investigation	Blue/Green: Simple investigation within the unit. Yellow/Red (or any Sentinel Event): Escalate to the hospital's Komite PMKP for a comprehensive Root Cause Analysis (RCA)	Blue/Green: direct supervisor + unit staff. Yellow/Red: Komite PMKP (multidisciplinary)	Blue: max 1 week. Green: max 2 weeks. Yellow/Red: max 45 days
5. Regrading	Review simple investigation results and reassess whether the initial grading was appropriate. If the risk is higher than initially assessed, regrade upward and initiate RCA	Hospital Patient Safety Team (Tim KP)	After simple investigation is completed
6. External Report	Submit an external report to the Komite Nasional Keselamatan Pasien (KNKP) under the Ministry of Health. KPC does not require external reporting	Hospital Patient Safety Team	After investigation and analysis are completed
7. Feedback and Learning	Report RCA findings and recommendations to the hospital director. Disseminate a safety alert or learning bulletin to all relevant units to prevent recurrence	Komite PMKP / Hospital Director	After RCA completion

Example Walkthrough

A nurse in the ICU prepares IV Potassium Chloride (KCl) at a concentration of 40 mEq but accidentally labels it as Normal Saline 0.9%. Before connecting it to the patient, the attending physician notices the discrepancy between the syringe content and the label, and the infusion is halted. The correct infusion is then prepared and administered.

Classification: KNC (Near Miss). The error occurred (mislabeling), but it was intercepted before the patient was exposed.
Grading: Impact would have been Major to Catastrophic (rapid IV KCl can cause fatal arrhythmia). Probability might be scored as 2 (Rare). Depending on the matrix intersection, this could grade as Yellow, triggering an RCA.
Learning point: The system worked because a second verification step (the physician) caught the error. The RCA would examine why the labeling error occurred in the first place and whether a systemic fix (e.g., separate storage of high-alert medications, mandatory double-check protocol) is needed.

5. National Patient Safety Goals

The six SKP, originally from PMK 1691/2011 and carried forward through subsequent regulations, form the preventive framework that aims to reduce the occurrence of all five incident types. They are frequently tested alongside incident classification:

SKP	Goal	Relevance to Incidents
SKP 1	Accurate patient identification (minimum 2 identifiers: name + date of birth)	Prevents wrong-patient errors (a common KTD)
SKP 2	Effective communication (read-back, SBAR)	Prevents miscommunication-related KNC and KTD
SKP 3	Safety of high-alert medications (LASA drugs, concentrated electrolytes)	Directly targets KPC involving dangerous drug storage
SKP 4	Ensuring correct site, correct procedure, correct patient in surgery (surgical safety checklist, site marking, time-out)	Prevents sentinel events such as wrong-site surgery
SKP 5	Reducing healthcare-associated infection risk (hand hygiene, bundles)	Prevents infection-related KTD
SKP 6	Reducing risk of patient falls (Morse Fall Scale, Humpty Dumpty for pediatrics)	Prevents fall-related KTD

6. Examples

Scenario	Why Students Pick the Wrong Answer	Correct Classification	Key Discriminator
A nurse gives Drug A instead of Drug B to the patient. The patient has no adverse reaction.	Students see "wrong drug given" and jump to KTD because it sounds like a medical error with consequences.	KTC (No-Harm Incident)	The drug reached the patient (ruling out KNC), but no injury resulted (ruling out KTD).
A pharmacist prepares Drug A instead of Drug B but catches the mistake and replaces it before dispensing.	Students classify this as KTC because an error occurred.	KNC (Near Miss)	The patient was never exposed. The error was intercepted before it left the pharmacy.
The emergency crash cart is found to have an expired epinephrine ampoule during a routine check. No patient needed it.	Students classify this as KNC because "something almost went wrong."	KPC (Potential Injury Condition)	No incident occurred. No error was made in patient care. This is a hazardous condition discovered through proactive surveillance.
A surgical team operates on the left knee instead of the right knee. The patient requires corrective surgery.	Students may classify this as KTD. Technically it is, but the answer the exam wants is more precise.	Sentinel Event	This KTD involves permanent or near-permanent harm requiring further intervention, meeting sentinel criteria. Wrong-site surgery is the classic sentinel event example in Indonesian regulations.
A patient receives the correct medication at twice the intended dose. The patient develops acute kidney injury.	Students may hesitate between KTC and KTD.	KTD (Adverse Event)	The patient was exposed and sustained measurable injury (AKI).

7. Traps and High-Yield Pearls

The most common way students lose points on this topic is by confusing KNC and KTC. Both involve an error in the care process, and both result in no lasting patient harm. The distinction is deceptively simple but must be applied precisely: if the patient was never exposed to the error, it is KNC. If the patient was exposed but nothing bad happened, it is KTC. The exam will use phrases like "sebelum diberikan kepada pasien" (before being given to the patient) to signal KNC, or "sudah diberikan tetapi tidak menimbulkan cedera" (already given but did not cause injury) to signal KTC. Read these signal phrases carefully.

A second common trap involves KPC vs. KNC. Students sometimes conflate the two because both represent "nothing happened to the patient." The difference is that KPC describes a standing hazard or dangerous condition found proactively (e.g., broken equipment, mislabeled storage), while KNC describes an active error in a care process that was caught before patient exposure. In KPC, there is no error event; the risk is latent. In KNC, an error did occur but was intercepted.

The third pearl: sentinel events do not require grading. The exam may present a sentinel scenario and ask about the next step. The answer is always immediate comprehensive RCA, not "perform grading first." Sentinel events bypass the color-band system entirely.

Finally, remember that the reporting culture in Indonesian patient safety regulations is explicitly non-punitive (no-blame culture). If the exam asks about the purpose of incident reporting, the correct framing is systems learning and prevention, not individual punishment. The goal of RCA is to identify system failures (process, environment, organizational factors), not to assign personal fault.

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