Prevention of Patient Safety Incidents Based on the Analysis of Nursing Service Quality in Hospital Rehabilitation Units in Jakarta

Abstract

Patient safety is a key indicator of healthcare quality that must be implemented across all hospital services, including addiction rehabilitation units, where the risk of interpersonal conflict and patient violence is relatively high. This community service activity aimed to analyze the quality of nursing care in preventing patient-to-patient violence in a hospital rehabilitation unit using the Donabedian framework and *Root Cause Analysis* (RCA). Data were collected through direct observation of the care environment, semi-structured interviews with nursing staff, quality document reviews, and a literature review. The findings were analyzed based on the structure, process, and outcome components of healthcare quality. The results showed that the rehabilitation unit had established Standard Operating Procedures (SOPs), a patient safety incident reporting system, and aggression risk screening at admission. However, several gaps were identified, including the absence of periodic aggression risk reassessment, limited monitoring of high-risk patients, suboptimal implementation of conflict de-escalation techniques, and the lack of specific quality indicators to monitor patient-to-patient violence. These conditions contributed to the occurrence of more than ten patient-to-patient fighting incidents during the past year. Improving the quality of nursing care should focus on strengthening continuous aggression risk assessment, enhancing nursing staff competencies, optimizing the monitoring of high-risk patients, and fostering a patient safety culture to reduce violence in hospital rehabilitation units.