Peran Dinas Kesehatan dalam Pelaksanaan Program Keselamatan Pasien di Puskesmas: Studi Kasus di Kota Yogyakarta

Muhammad Hafiz Haunan, Dr. dr. Hanevi Djasri, MARS, FISQua

2025 | Tesis | MAGISTER KEBIJAKAN DAN MANAJEMEN KESEHATAN

Latar Belakang: Meskipun Permenkes No. 11 Tahun 2017 menegaskan peran Dinas Kesehatan dalam membina dan mengawasi keselamatan pasien, studi masih berfokus pada pelaksana di fasilitas kesehatan. Pedoman yang ada pun hanya mengklasifikasikan peran pemerintah pada level rumah sakit, padahal secara struktural Puskesmas adalah unit pelaksana teknis Dinas Kesehatan. Di Kota Yogyakarta, laporan mutu dan insiden menunjukkan perlunya perhatian terhadap pelaksanaan kegiatan keselamatan pasien di Puskesmas. Kerena itu, peneliti menggeser fokus untuk menjelaskan peran yang dijalankan Dinas Kesehatan dalam pelaksanaan keselamatan pasien di Puskesmas Kota Yogyakarta.

Metode: Penelitian ini menggunakan pendekatan kualitatif dengan desain single revelatory case study untuk mengeksplorasi peran Dinas Kesehatan dalam pelaksanaan program keselamatan pasien di Puskesmas Kota Yogyakarta, dengan mengacu pada The Ecosystem for Implementation of the Global Patient Safety Action Plan 2021–2030 Framework.

Hasil: Dinas Kesehatan Kota Yogyakarta menjalankan lima peran utama dalam pelaksanaan program keselamatan pasien di Puskesmas, yaitu advokasi, mobilisasi sumber daya, penciptaan pengetahuan, kolaborasi, dan dukungan implementasi. Namun, kelima peran tersebut belum menyentuh seluruh aspek program secara komprehensif. Fokus Dinas Kesehatan masih terbatas pada aspek administratif seperti pelaporan IKP, tanpa verifikasi mendalam. Di tingkat Puskesmas, program keselamatan pasien dijalankan melalui komitmen pimpinan, penilaian/pengkajian terhadap sasaran dan budaya keselamatan pasien, rencana aksi, tim implementasi, peningkatan keselamatan pasien dan pengurangan/penurunan bahaya yang merugikan. Meski demikian, pembelajaran dari insiden belum konsisten dalam mencegah kejadian berulang.

Kesimpulan: Dinas Kesehatan perlu memperkuat inovasi kebijakan dan kapasitas TPCB guna memastikan implementasi keselamatan pasien di Puskesmas berjalan responsif, kolaboratif, dan berorientasi pada perbaikan berkelanjutan.

Background: Although Ministry of Health Regulation No. 11 of 2017 affirms the role of District Health Offices (DHOs) in fostering and supervising patient safety, existing studies remain focused on healthcare facility-level implementation. Current guidelines primarily classify government roles at the hospital level, even though Puskesmas are structurally technical implementing units under the DHOs. In Yogyakarta City, quality and incident reports indicate the need for greater attention to patient safety implementation at the Puskesmas level. Therefore, this study shifts the focus to explore the roles undertaken by the DHO in implementing patient safety programs in Puskesmas. 

Methods: This study employed a qualitative approach with a single revelatory case study design to explore the role of the Yogyakarta City Health Office in implementing patient safety programs in Puskesmas, guided by the Ecosystem for Implementation of the Global Patient Safety Action Plan 2021–2030 Framework. 

Results: The Yogyakarta City Health Office performed five key roles in implementing patient safety programs in Puskesmas, namely advocacy, resource mobilization, knowledge creation, collaboration, and implementation support. However, these roles have yet to comprehensively address all aspects of the patient safety program. The Health Office’s efforts remain largely focused on administrative tasks such as incident reporting (IKP), without thorough verification. At the Puskesmas level, patient safety programs were implemented through leadership commitment, assessment of patient safety goals and safety culture, action planning, implementation teams, patient safety improvement, and harm reduction. Nevertheless, learning from incidents has not been consistent in preventing recurrence.

Conclusion: The District Health Office must strengthen policy innovation and build the capacity of the TPCB to ensure that patient safety implementation in Puskesmas is responsive, collaborative, and oriented toward continuous quality improvement

Kata Kunci : peran dinas kesehatan, patient safety, puskesmas