Hospital X's Effective Strategy in Improving Patient Safety in the Era of the COVID-19 Pandemic

Patient safety issues during the Covid-19 pandemic and the strategies implemented to improve it. This paper aims to find out strategies in improving patient safety in the era of the COVID-19 pandemic. This research is included in the type of descriptive qualitative research with case study methods or approaches (Case Studies) and observations. The results show that six patient safety goals have been implemented, but management support is needed to improve patient safety, especially in terms of optimizing service quality, regulatory policies, socialization, and staff training. Lack of officer awareness and commitment to incident reporting are obstacles to changing safety cultures. Strategy optimization is carried out by improving human resources and meeting patient perceptions of patient safety, such as services in accordance with procedures, handling speed, cleanliness of standardized rooms and infrastructure, and the availability of patient aids in hospitals. Optimization of the strategic plan is carried out by streamlining human resources (HR), patient perceptions of patient safety in hospitals including services that are in accordance with procedures, services based on handling speed, the presence of officers who are always on standby, responsive and competent attitudes, information about the flow of hospitals and clear patient referral systems, cleanliness of standardized rooms and infrastructure, completeness of waiting room facilities, and the availability of patient aids in hospitals.


INTRODUCTION
Describe the background of the problem, the objective and benefits of research, theoretical study, and In early 2020, the world was shocked by the outbreak of new pneumonia or virus originating in Wuhan, Hubei Province. The virus spreads quickly to various countries and is called Coronavirus Disease 2019 , caused by the SARS-COV-2 virus. There is still controversy surrounding the enforcement of the diagnosis, management and prevention of this disease. From December 31, 2019 to January 3, 2020, there was a rapid increase in cases, with 44 reported cases. Not until one month, the disease spread to various other provinces in China, Thailand, Japan, and South Korea. Covid-19 was first reported in Indonesia on March 2, 2020 with two cases. Data on March 31, 2020 showed that there were 1,528 confirmed cases and 136 deaths. Indonesia's Covid-19 mortality rate in Southeast Asia is the highest, reaching 8.9%. Because Covid-19 is very contagious, prevention efforts must be taken seriously, including by complying with health protocols such as maintaining physical distance, washing hands, and wearing masks. (Lubis, 2020) On March 11, 2020, WHO declared Covid-19 as a global pandemic that had a major impact on the healthcare system. Changes to the design of hospital services are necessary but may increase the risk to patient safety. The lack of health workers increases the potential risk because the workload becomes higher, and other factors at risk include actions that are not in accordance with procedures, the administration of drugs that are not yet evidence-based, the large number of uncontrolled studies, poor clinical services, and an unsafe work environment due to the risk of virus transmission. Service delays occur due to fear of coming to the hospital, lockdowns, patients with chronic illnesses who do not receive outpatient services, doctor's practice schedules that do not meet the needs of patients, or patient restrictions because the hospital is overloaded. (Amelia Nurdin et al., 2021) With the increasing potential risk of patient safety during the Covid-19 pandemic, hospitals must have strategic planning to improve patient safety. The increase in Covid-19 cases has developed so that it requires agility in making hospital strategic plans to face challenges and demands of problems that are difficult to predict. With the surge of patients in hospitals, hospitals are unable to provide maximum service and problems arise that result in meeting the needs of facilities in hospitals, including the placement of officers, patient beds, logistics stocks such as personal protective equipment (PPE), medicines, disinfectants, O2 gas, linen, medical devices, to financial problems in hospitals. (Francisco, 2020) RSKIA PKU X was founded by Persyarikatan Branch X which has been started since 1928 in the east of Kotagede Market. The service activities are centered on Jalan Kemasan No. 43 Kotagede Yogyakarta, on the land of Muhammadiyah waqf. After going through several stages of development, finally on May 31, 2007, it has received a Permanent Permit as a Special Hospital for Mothers and Children from the Provincial Health Office of the Yogyakarta Special Region with Permit Number 445/2867/IV.2..
Covid-19 poses a tremendous challenge for RSKIA PKU X, so hospitals must make rapid changes to service design so as to increase the risk of patient safety incidents. Data for 2020-2021 shows that the number of confirmed Covid-19 patients is 777, and 1 patient has died. The potential risk is due to the lack of health workers because there are health workers who have been confirmed with Covid-19 so that they have to isoman causing the workload to be higher, there is an increase in the need for hospital facility capacity due to the impact of the surge in patients, namely the need for isolation rooms, staff placement, personal protective equipment (PPE), medical devices, medical gas, disinfectants, medicines etc. In addition, the hospital is also experiencing financial constraints. Patient safety in hospitals is influenced by implementing patient safety goals and culture in hospitals, both during the Covid-19 pandemic and non-pandemic conditions, so strategies are needed to increase patient safety at RSKIA PKU X and provide solutions in dealing with disruption.
Based on the results of research on Improving Patient Safety at Home During the Covid-19 Pandemic, it is stated that knowledge related to the prevention, treatment, and handling of Covid-19 is still very limited because it is a disease that was only discovered in 2019. The main preventions that can be done include breaking the chain of transmission by isolating, early detection, and carrying out basic protection. (Lubis, 2020) In another study, several examples of incidents during the Covid-19 pandemic were reported, namely patient identification errors, ineffective communication, improper disinfection of rooms and medical devices, errors in patient placement, lack of knowledge of officers, errors in supporting examinations, improper treatment, administrative processes that are not in accordance with procedures, to limited resources. Although Covid-19 is a new type of virus, strategies in patient safety are expected to always be implemented properly. (Amelia Nurdin et al., 2021) From the description above, the problems that arise about patient safety during the Covid-19 pandemic require strategic planning on service problems in hospitals so the author wants to conduct a study entitled Strategies to Improve Patient Safety in Hospitals during the  Pandemic Case Study at the Special Hospital for Mothers and Children (RSKIA) PKU X. What Are the Strategies to Improve Patient Safety in Hospitals During the Covid-19 Pandemic at RSKIA PKU X?
Covid-19 is a new viral disease that has never been found in humans before. The virus that causes Covid-19 is called Sars-CoV-2. The coronavirus is zoonotic (transmitted between animals and humans). It is not yet known for sure which animals are the source of transmission of Covid-19. Covid-19 can be transmitted through coughing/sneezing splashes (droplets) from human to human, People who are very at risk of contracting this disease are people who are in close contact with Covid-19 patients, including those who treat Covid-19 patients (Ministry of Health RI, 2020) Acute respiratory disorders are common signs and symptoms of Covid-19 infection. Other symptoms include fever, cough, and shortness of breath. The average incubation period is 5 -6 days with an incubation period of fever, cough and shortness of breath. In severe cases, Covid-19 can cause pneumonia, acute respiratory syndrome, kidney failure, and can lead to death. (Princess, 2020) The spread of this virus is very fast from the country of China to the rest of the world. On March 11, 2020, the World Health Organization (WHO) declared the Covid-19 outbreak a global pandemic and had a major impact on the health care system. Covid-19 is a new challenge forcing hospitals to make rapid changes that will actually also increase the risk of patient safety incidents. (Amelia Nurdin et al., 2021) Explained in the Journal of Medika Hutama entitled Improving Patient Safety During a Pandemic: Literature Review (Amelia Nurdin et al., 2021), several strategies that contribute to improving quality and patient safety during the Covid-19 pandemic, namely:

Strengthen the Organizational System
Officers' skills in improving patient quality and safety play a very important role in implementing change. Hospitals need to assess pandemic readiness by analyzing the current situation. This assessment can use the WHO Rapid Hospital Readiness Checklist for Covid-19. The results of the assessment will guide which areas need improvement. There needs to be a change in the strategies and standards of care developed to balance patient safety and officer safety. Research adds, forms and activates task force teams and makes clear regulations about their respective duties, responsibilities, and authorities. Support from the leadership is highly expected during this pandemic. The allocation of budget and manpower must be adequate. Leadership and developing a safety culture are key pillars for shaping a secure system. Research says, poor organization becomes a contributing factor in injuries in patients. Minimize risk by creating compliance checklists and direct observations. One of the concepts of quality improvement is "Going to the Gemba" which in Japanese, Gemba means "real place" which means the leader makes observations, observes work and involves officers in making decisions. Build positive changes in the organization to promote patient safety strategies and innovations and make the service system safer from potential risks that existed before. Increase knowledge by reading references from other countries in the world in overcoming the challenges of the health service system during the Covid-19 pandemic and disseminate these new things to all officers orally or in the form of guidelines and clinical flow.

Support Patients and Empower Communities
Facilitating the prevention, treatment, and treatment of Covid-19. The patient is the main actor who is harmed in the event of an incident. Involve the patient from the beginning to the end of the treatment process. Hospitals need health promotion strategies so that people implement clean living behaviors that are in accordance with health protocols. Communication must be transparent and up to date inside and outside the hospital to raise public awareness. Support patients from a psychosocial point of view because isolation will have an impact on the patient's mental health. Socialize self-management tools to patients with chronic diseases who do not have access to health facilities or hospitals during the Covid-19 pandemic. Create sharing sessions from Covid-19 survivors to give strength to patients and provide opportunities for patients to contact their families virtually. Implement a patient centered care system and use the term physical distancing, rather than using the term social distancing. Patients with a diagnosis of Covid-19 are one that requires long enough treatment in the hospital. Health workers are at the forefront of providing medical interventions to patients to influence their behavior in protecting the health of patients, families and communities. Stay focused on preventing the spread of Covid-19 during interactions with patients and educate them to maintain health so that transmission during patient care can be prevented and ultimately does not increase the workload of health workers.
Increase Safety In Care Use a screening system to identify suspected cases before the patient enters the examination room of a non-infectious patient. Also separate sterile and non-sterile grooves for the patient's tools and linen. Reduce the number of outpatient visits to the hospital, make appointments and time patient visits so that there is no buildup that will endanger patients. The use of patient waiting rooms must implement social distancing protocols. The design of the operating room was also changed following the rules for preventing the transmission of Covid-19. The use of technology and information systems has never been more important than during a pandemic. If implemented properly, technology and information systems can improve patient safety by improving team communication and facilitating patient care during the Covid-19 pandemic. Take advantage of the teleconferences that have now been recommended to connect doctors with patients who need home care. Strengthen the hospital's technology system to facilitate patient care. Design a special electronic record during this pandemic.

Minimize the Risk of Injury
Judging from the workload and challenges of officers during this pandemic, it requires proactively developing skills and education. Organize training and continuously refresh the officer's knowledge of the correct use of medical devices and donning doffing steps. To make it more efficient, make it in the form of a video and share it on the hospital site. All health workers who perform patient care must be educated in the science and practice of patient safety. Patient safety should be embedded in officer education and training programs at all levels. Provide training on teamwork including effective communication, monitoring and mutual support. Socialize the new guidelines and information about the situation that needs to be improved. Make sure the patient's hand over process is structured and running properly. Develop decisions quickly and evaluate them continuously. Plan training and simulations on a regular basis that include donning doffing and surface disinfection. Leaders should continue to promote a culture of safety for all officers and ensure policies and procedures are implemented effectively. Develop integrated patient safety systems and programs that connect occupational health and safety with patient safety and infection prevention and control.
Do brainstorming activities about risks and potential failures followed by risk mitigation. It requires designing a new system to change the behavior that needs to be changed to make it easy to do such as washing hands or using personal protective equipment according to procedures. Hospitals should also make periodic environmental disinfection schedules, use medical devices in accordance with procedures and try to use disposable equipment to minimize transmission from one patient to another. The physical and psychological health of officers is critical to ensuring they can provide safe care and avoid patient safety incidents and contribute to safer care. The safety of health workers and the safety of patients are inseparable. Develop national programs related to the safety and health of officers as an effort to strengthen the Health system.

Improve the Learning System
Improving the quality of health services involves designing, implementing, and studying the system changes that need to be made in the need for health services. The goal of quality improvement during a pandemic must be to ensure good outcomes for patients. All improvement requires a change in the behavior of individuals and groups. The leadership factor has become even more important during the pandemic. Maintain teamwork and effective leadership. Ensure effective communication always occurs in every service process including patient hand over. The leader must involve the officer in solving the problem and drafting the solution. (Francisco, 2020) Conducting research with the title Hospital Strategic Planning in the Era of Pandemic Vuca (Volatile, Uncertain, Complex, Ambiguous) Corona Virus Disease 2019 (Covid-19): Literature Review. The results of this study state that hospitals need to make strategic planning by making steps that provide solutions to all problems that are being faced by hospitals caused by health disruption during the Covid-19 pandemic. Organizational reform is appropriately needed for hospitals to respond to these conditions, prioritize patient safety, uphold service ethics, professionalism, build strategic leadership, and carry out risk management. agility (agile), all of this requires support and collaboration of corporate governance and effective hospital clinical governance, . The difference in this research is using the PRISMA Study Method. Journals used from English-language journals are limited to hospital strategic planning in the era of the Covid-19 pandemic (Proquest, Google Scholar, and ScienceDirect). This systematic analysis was carried out on articles published in 2020. (Princess Handayani1, Kiki Hardiansyah Safitri2, 2021) Conducted a study entitled Literature Review: The Implementation Of Patient Safety During The Covid-19 Pandemic. The result of this study is that patient safety concerns during the Covid-19 pandemic are related to personal protective equipment (PPE) and visitation restrictions to be very useful information when determining preventive measures in response among health workers and to increase their productivity during the Covid-19 Pandemic emergency situation, or other similar emergency measures in the future that require the same approach as a priority. The difference in this research, the type of writing used is a literature review study that focuses on writing results related to the topic or writing variables.
(Amelia Nurdin et al., 2021) her research entitled: Improving Patient Safety in the Covid-19 Pandemic: Literature Review. The results of this study state that patient safety must always be a priority in hospital services even during the Covid-19 pandemic. Strategies that can be carried out to improve patient safety during the Covid-19 pandemic are strengthening organizational systems, supporting patients and empowering the community, improving safety in care, minimizing the risk of injury, and improving the learning system. The difference in this study is that the Literature Review of reference searches used is sourced from online journals consisting of PubMed, ISQua and Google Scholar. The references used are in English and are limited in 2020.

METHODS
This research is included in the type of descriptive qualitative research with case study methods or approaches (Case Study) and observation. Case studies are included in descriptive analysis research, that is, research carried out focused on a particular case to be observed and analyzed carefully until it is completed. Cases can be singular or plural, for example individual or group. The analysis is carried out in depth on all factors related to the case so that appropriate conclusions can be obtained. (Muhlisian, 2013) The phenomenon that is the case in this study is a strategy to improve patient safety during the Covid-19 pandemic Case Study at RSKIA PKU X. The subject of this study was hospital management consisting of medical and non-medical staff, nurses, and patients. The research site at RSKIA PKU X. Research was conducted for 3 (three) months, namely July-August-September 2022. Participants in this study were employees at RSKIA PKU X which consisted of 7 hospital management, 7 emergency room nurses, 7 ward nurses, 5 poly nurses and 9 patients. Participatory must meet the desired criteria because it is part of the target population to be studied directly, the group of subjects that must meet the inclusion and exclusion criteria. The inclusion criteria used are as follows: Willing to be a research respondent, Hospital management (medical and non-medical staff), Emergency Room Nurse, Ward and Polyclinic, Outpatient in Polyclinic (general poly, pediatric poly, poly obsgin), Inpatient in pediatric ward and puerperal ward. The exclusion criteria used are as follows: Hospital management and Health Workers with a service period of less than 1 year Patients who have hearing and vision impairments and mental disorders. The sampling technique in this study uses purposive sampling technique, namely sampling technique by determining certain criteria (Sugiyono, 2008). The purpose of purposive sampling is to produce samples that can logically be representative of the population. How to take consecutive sampling, which is to take every day until the amount is reached.

. PKU X Special Mother and Child
Hospital is a special type C hospital with 48 TT that has 24hour emergency installation, outpatient, inpatient, medical support services and facilities and infrastructure. Overview of the characteristics of the participants.
Participants in this study consisted of 7 hospital management, 19 nurses and 9 patients. The hospital management participants who were interviewed consisted of the deputy director of general affairs and finance, the head of general affairs and RT, the head of medical services, the head of medical support, the head of nursing, the head of administration and SDI, and the head of finance with a service period of between 4 years and 31 years. The nurses who were observed consisted of 3 units, namely emergency room nurses, ward nurses and polyclinic nurses. The patients interviewed were polyclinic patients and inpatient ward patients with backgrounds of various professions and ages from 24 years to 50 years.

Implementation of patient safety goals
Implementation of targets there are six targets implemented in patient safety with the accuracy of patient identification, improvement of effective communication, improvement of safety of drugs that must be supervised, certainty of surgical locations, correct procedures and surgeries, reduction of the risk of infections related to health services and reduction of the risk of injury to patients due to falls.
One of the improvements in drug safety is with a double check. Double checking examination is defined as verifying the correctness and suitability of the components of the drug administration process by using two nurses in checking before the drug is given. Double checking is precisely as a procedure where two individuals, preferably two practitioners separately examine each component in drug administration. The second practitioner should check the drug, dosage, calculation, IV fluid and the patient's identity before administration. It is worth mentioning that the point of the examination procedure is that nurses are expected to find common ground in the information they manage. If a nurse finds different results, resolving the differences that arise must be done before the drug is given to the patient (Halawa et al., 2021).
Before and during the COVID-19 outbreak, patient identification was different. Officers serving patients who are more focused on the condition of COVID-19 patients appear to be a matter of this identification. Communication during the COVID-19 pandemic decreased because nurses were faced with a new disease that caused concerns in transmission, the use of complete PPE so that the voice was less clearly heard (Sudarmika et al., 2021).
The implementation of the patient safety target has changed during the COVID-19 pandemic where the target in reducing the risk of infection related to health services is getting stricter because it prevents the spread of the virus. The interview above revealed that health workers are required to comply with health protocols by washing hands, using masks and full PPE, especially when handling COVID-19 patients, supported by regular room sterilization and the availability of hand scoon and hand sanitizer facilities. For patients, screening is carried out to separate infectious and non-infectious patients, maintain distance in the patient's waiting room and limit patient visiting hours.
Service changes were made by hospital groups during the COVID-19 pandemic, (1) Everyone entering the surrounding area must always wear a medical mask; (2) The designated personnel on duty at the front door manage the reception of patients and visitors, only for justifiable reasons. All participants must have their temperature measured and disinfect their hands; (3) If there is a fever, he must be immediately transferred to the examination room; (4) An examination station is installed outside the emergency room. Emergency room staff take turns guarding the room (Chen et al., 2021).
During the COVID-19 pandemic, there was a change in patient safety goals, which was further tightened, especially in reducing the risk of infections related to health services. In line with previous studies that during a pandemic, infection prevention and control must be carried out very strictly considering the very fast transmission of the virus so that the negligence of nurses not only harms patients, but can harm themselves and colleagues (Galleryzki et al., 2022).
Based on the results of previous studies, theories and studies showing that patient safety has been carried out according to six patient safety targets, but during the COVID-19 pandemic, patient safety is carried out more strictly, especially in reducing the risk of infections related to health services. This can be seen from the existence of patient screening, patient health protocols and health workers.

The carrying capacity of management in patient safety
Optimizing the quality of hospital services can be a support for management in the implementation of patient safety. Hospitals are known to provide quality services to patients in accordance with indicators in patient safety. In addition, hospital services must be provided plenary. Service quality improvement systems, such as accreditation, are useful tools for improving safety culture. The health service manager must allocate the necessary resources to keep pace with the system and attract the participation of all members of the healthcare team (Farokhzadian et al., 2018).
Socialization of patient safety is one of the important things so that its application can run optimally. The health officer explained that there are already regulations on patient safety socialization and have been implemented. However, socialization is not carried out regularly to health workers. Socialization has been carried out jointly by all staff, but it has not been carried out continuously. As for new staff, socialization is always carried out independently related to patient safety. Socialization that has been carried out such as the use of APAR, BHD, Code Blue, Code Red.
The hospital has conducted a cultural survey, but the follow-up to the safety culture survey has not been carried out. Evaluation of patient safety culture allows us to recognize the potential and weaknesses that will guide corrective actions to build a positive and strong culture within healthcare institutions. Teams of healthcare workers especially nurses have a large contingent of hospital human resources and, most of the time, are directly responsible for care, so the evaluation of patient safety culture brings important information and has an impact on hospital institutions (Costa et al., 2018).
The COVID-19 pandemic has made it difficult to socialize because it has not been done for a long time and focuses on patient services according to health protocols. In addition, not all health workers know Code Blue and need training. This is also in line with previous research that in the implementation of patient safety, increasing understanding can be done by providing continuous education and training to health workers (Tanjung et al., 2021). Patient safety is a key pillar of any healthcare system. There needs to be investment in infrastructure and human resources, and implementing patient safety training workshops/sessions (Abraham et al., 2022).
The implementation of patient safety will run well if it is supported by supporting facilities and infrastructure. The hospital organizes optimal service support activities, one of which is by replacing the latest rongent aircraft that already use the latest technology so that there is no B3 waste. However, there are many obstacles in implementing patient safety related to buildings and rooms. Some of these obstacles include limited narrow space, inappropriate road access, old buildings that need renovation, the provision of isolation rooms during a pandemic that is not up to standard. This can cause the application of SOPs to be not optimal which can improve patient safety.
Previous research showed that existing hospital facilities in India that provide outpatient services were constrained in their functioning during the COVID-19 pandemic due to weak infrastructure that contributed to patient safety and suboptimal infection control measures. Infrastructure and infection control deficits in hospitals were reported in terms of limited physical space and queuing capacity, lack of separate entry and exit gates (n=25.49%), inadequate ventilation (n=29.57%), and negligible airborne infection control measures (n=38, 75.5%) (Garg et al., 2020).
The COVID-19 pandemic has also had an impact on the financial condition of hospitals, where hospital opinions have decreased. In addition, the need for infrastructure in fulfilling health protocols is also increasing, which has an effect on increasing hospital costs. This condition is supported by the results of previous studies that hospital performance is measured with a perspective on the balanced scorecard, there is a significant impact of the COVID-19 pandemic on performance seen from four perspectives, one of which is the financial aspect. From a financial point of view, it is affected by a decrease in income and the amount of expenses. The customer perspective shows a decrease in the number of patients caused by entry restrictions. The internal perspective of business processes has operational constraints. Meanwhile, the perspective of learning and growth is impacted by the high stress experienced by employees (Zeho et al., 2020).
To provide a culture of patient safety, it is necessary to develop a plan to increase the voluntary participation of health professionals and their commitment to safety. Hospitals should provide more resources and support for health professionals (Lee et al., 2022). Previous studies have shown how patient safety is when operating under the conditions of the COVID-19 pandemic, several factors remain important to drive a culture of patient safety. Strengthening patient safety practices is a must under these conditions. Most of the modifiable factors are related to the workplace and include the preparation of previous procedures, restrictions on extending daily working hours and psychological counseling for staff (Malinowska-Lipień et al., 2022).
Based on the results of research, theory and previous research, it shows that the application of patient safety requires management support both in terms of optimizing service quality, sustainability of socialization, and training needs. However, there are several hospital obstacles including financial limitations due to declining income, and also inadequate infrastructure due to rooms that are not up to standard and the condition of the old building.
Officer awareness in changing safety culture During the COVID-19 pandemic, there was a change in habits in the implementation of patient safety. These changes will affect the culture of patient safety. Some of the changes include regulatory policies, the use of masks, PPE and so on. The implementation of patient safety in hospitals has been good in its implementation, but human resources experience a high workload. During the pandemic, hospitals lacked human resources because they had to isolate, which impacted the emergency room service not opening. Another obstacle is that there are still human resources who do not understand the reporting of patient safety incidents and the double work that must be done.
The implementation of patient safety will not run well without a good teamwork climate. Effective communication is needed so that it is able to coordinate well between officers. In addition to effective communication, regular coordination is also carried out so that there is a common perception. A stable team that blends less experienced personnel with more experienced personnel; a strong, interprofessional, and collaborative atmosphere; strong informal consulting culture; and wise, the use of more flexible rules and regulations proved important in the face of the COVID-19 pandemic (Hennus et al., 2021).
The compliance of officers in patient safety is known to be less compliant. This is due to the understanding of different goals. Information from health workers is also known that officers are not compliant in implementing existing policies in hospitals. The results of the observation list found that there were still officers who did not provide information or take precautions against the risk of patients falling and a small part had not washed their hands in accordance with the SOP.
Nurses' compliance and thoroughness with the procedures implemented in the hospital, the strictness of the supervisory team to the use of PPE, and the performance of nurses while in the room, are important keys to the successful implementation of the Patient Safety Goals (SKP) during the COVID-19 pandemic. SKP's achievements in this study are in good condition. However, it is not in accordance with the standards set by the Hospital Accreditation Commission (KARS), which is 100%. Therefore, there is a need for further improvement by assessing the factors of SKP implementation (Galleryzki et al., 2022).
Previous research studies found that there were some participants giving the impression that the hospital's patient safety culture was suboptimal in certain aspects. A number of factors that hinder the formation of a positive culture in hospitals include infrastructure, staff attitudes, lack of patient safety awareness and reporting of adverse events (Abraham et al., 2022). During the COVID-19 pandemic, a number of patient safety concerns have been identified including low communication openness and current punitive responses to errors, which may cripple healthcare workers in reporting adverse events. Poor teamwork across the unit was identified as another problem, as well as low staff compliance (Brborović et al., 2022).
Based on the results of research, previous theories and studies have shown that officer awareness is lacking in changing safety culture during the COVID-19 pandemic. Officers are constrained in implementing the new culture, there are still officers who are less compliant in implementing hospital patient safety policies and staff understanding is still lacking. However, it is known that there is effective communication and coordination in carrying out work between officers, this shows a good teamwork climate in supporting patient safety.

Incident reporting commitments
Incident reporting is an important part of learning and needs to be done if organizations are to implement a fair culture that is error-free and with clear accountability. Incident reporting is also an illustration of how committed health workers are to honesty in doing their work, whether it is in accordance with existing SOPs. The flow in reporting must have clear regulations so that the mechanism can run well. Reporting mechanisms can be carried out in accordance with the grading of incidents.
Internal incident reporting is done by staff in each clinical unit to the Quality Team. Incidents are reported to the Quality Team shortly after the incident occurs as well as incidents that have completed investigations and their resolution (Islami et al., 2018). Reporting can be done by health workers through the head of the unit followed by the IKP RS team. Incident reports are discussed in meetings to find solutions and then follow-up will be carried out by the IKP RS team and directors. Assessment of patient safety and the implementation of measures should be a priority for all professionals, especially those who are at the top of the organizational chart so that positive results are evidenced in the work process in the field of patient safety. Institutions should provide a means to contribute to the analysis of their work processes, especially to prioritize patient safety through good structural working conditions for professionals and knowledge of existing problems in order to minimize them and avoid them where possible (Costa et al., 2018).
Reporting of patient misconduct incidents is done in writing which means that reporting is done manually. Some of the existing reporting support units include a person in charge, an incident reporting form, and also a simple investigation form. This reporting mechanism certainly needs to have the carrying capacity for the availability of incident reporting forms. Interviews with health staff are known to support the reporting of service units already in place. This is also in line with other research studies that facilities and infrastructure in supporting patient safety, one of which is the reporting book in each clinical unit (Islami et al., 2018).
The frequency of reporting patient safety incidents still needs to be improved. Patient safety incident reporting activities are carried out in accordance with the incident reporting flow, which is followed up by the PPI team and hospital directors. Incident reporting is still done manually by writing incident reporting forms as well as simple investigation forms. In addition, the frequency of reporting is still lacking due to forgetting to report or there is an element of intentionality not to be reported. This indicates that a firm commitment is needed in reporting patient safety incidents.
The system of data reception and error reporting is obliged to conduct a radical analysis of safety events, analysis of findings, diffusion of corrective actions, and provision of feedback to staff. Nurses believe that the lack of some measures, for example the delivery of reports, feedback to staff, and the follow-up of their feedback, indicates the lack of importance of reporting and the weakness of safety culture (Farokhzadian et al., 2018). Previous research studies have found that the patient safety culture at 'X' Palembang Hospital is still not good enough, this can be seen from the large number of patient safety incident reports from the KPRS team. In fact, this type C hospital is obliged to implement a culture of patient safety in improving the quality of health services (Agustina, 2018).
Previous research studies have found that incidents and injuries of healthcare workers are recorded primarily by nurses and nursing assistants with an average incidence prevalence of 3.5% annually. Common injuries are syringes, hardness at work, injuries during manual handling of the patient. Injuries of patients and health care workers are still prevalent in the Swedish health service and most incidents involve patient situations. Collaboration between employers, employees, and patient representatives is necessary to raise awareness of safety in healthcare (Wåhlin et al., 2020).
Based on the results of research, theory and previous research show that commitment to incident reporting is needed because incident reporting is still lacking, even though an incident reporting form has been provided. In addition, the reporting flow is clear, starting from the reporting of each unit to the head of the unit, then the IKP RS team which will then be followed up by the team and the hospital director.

Strategic plan optimization
The health staff explained that there is a rotation of human resources in accordance with the condition of health workers during the COVID-19 pandemic. Another effort in the patient safety strategy is to increase HR compliance in implementing health protocols. Health workers should wear masks, wash their hands, keep their distance and use PPE according to the risk zone. Another patient safey strategy is to fulfill HR facilities by providing immune supplements. This can maintain the health condition of health workers in providing services to patients so that human resources are also more effective.
Efforts in instituting clinical governance, developing and improving the physical infrastructure of hospitals, providing the necessary human resources, ensuring staff receive patient safety education and promoting "good" communication and information systems, all identified as important processes and strategies for improving patient safety in the Bhutanese health system (Pelzang and Hutchinson, 2018). Safety perceptions, management support, and supervisor/manager expectations are key drivers of patient safety levels. More specifically, safety issues in work units and the work climate provided by hospital management are specific drivers of patient safety outcomes (Simsekler et al., 2020).
Hospitals increase the supply of necessities by supplying consumables and medicines. This is done because of the increasing need for hand hygiene and the increase in variable drugs in treating COVID-19 patients.
Based on the Regulation of the Minister of Health of the Republic of Indonesia Number 72 of 2016 concerning pharmaceutical service standards in hospitals that needs planning is an activity to determine the number and period of procurement of pharmaceutical preparations, medical devices and consumables in accordance with selection activities to ensure the fulfillment of the right type, right quantity, on time, and efficient criteria (Relly et al., 2022).
Strategy in terms of human resources and supplies, the hospital also tightened policies during the COVID-19 pandemic including changes in services, management supervision and policies related to hospital finances. Hospitals need the cooperation and involvement of all hospital staff in implementing patient safety, especially during a pandemic. Hospitals make regulations related to service changes by screening non-COVID COVID patients, monitoring and evaluating programs and also optimizing the supervision of each service unit. In addition, the hospital also strengthened its policy on finances.
Strategy optimization can also be done by making financial efficiencies based on the priority scale. Management also made a Budget Work Plan (RKA) related to the staff training program, where it was discovered that there were still staff who did not understand about patient safety. Ensure the care provided in this setting is safe, effective and focused on the needs of the patient; It should be a top priority for policymakers and practitioners. Safe primary and outpatient care improves the health and wellbeing of individuals, communities, and communities. Training and development programs should be available to clinical staff and support staff throughout their careers so that patient losses can be minimized (Kuriakose et al., 2020).
A room that complies with the SOP is needed to support the implementation of patient safety. During the pandemic, the hospital added room skates, arranged room circulation and prepared isolation rooms for COVID-19 patients. The determining factors of disaster management at Bethesda Yogyakarta hospital based on space aspects are changes in spatial planning, preparation and use of isolation rooms, preparation of space escalation, and flow to isolation rooms (Utami et al., 2021).
The hospital strives to prepare isolation rooms both in the emergency room and in the treatment ward and for officers also provided different pathways when leaving and entering the hospital. The arrangement of the room in accordance with the PPI is the addition of a partition between the patient and the doctor and the arrangement of circulation in room 2 to prevent and control infection. Development/improvement of physical/environmental infrastructure, highlighted the importance of patient safety from safe physical infrastructure and safe environment. Safe infrastructure is characterized as a powerful building with adequate space, a good navigation system (for example, signs), a built-in oxygen system, ramps, electrical elevators, ventilation systems and good natural lighting. A safe environment is characterized as promoting physical safety, such as giving the patient an orientation upon entry and maintaining cleanliness. The provision of equipment, such as wheelchairs and beds with side rails, is also considered a core element of patient safety (Pelzang and Hutchinson, 2018).
Efforts in optimizing the strategic plan for patient safety implementation are also inseparable from the indicator system. Update the system with an integrated system or referral system and also add doctor services with teleconsul. SISRUTE is an internet-based information technology that can connect patient data from a lower service level to a higher or equivalent service level (horizontal or vertical) with the aim of simplifying and accelerating the patient referral process (Dinkes DIY, 2020). The Sisrute application is very helpful in accelerating services, making it easier for referral information related to patient clarity to be accepted by the referred hospital, easy to consult in more targeted patient care and minimizing patient rejection with coordination and communication between hospitals (Awalludin et al., 2022;Bancin et al., 2020).
Digital health plays an important role in health services. Various types of technologies such as personal health monitoring applications, mobile applications, telemedicine, and various health information systems are used to support the delivery of better health services. Digital health support roles for COVID-19 management include roles in conducting patient data management, providing information related to COVID-19, teleconsultation, electronic medical records, and monitoring population mobility (Andriani and Hakam, 2022). The results of interviews in this study are known to have used doctor teleconsultation using the whatsapp application but the hospital has not used electronic medical records.
Optimization of the strategy plan is carried out by streamlining existing human resources, increasing the supply of consumables, tightening policy regulations, utilizing spatial planning and updating the service system. This is the potential of the hospital so that the implementation of patient safety can run optimally.

Patient perception of Patient safety
Patient safety is a framework of organized activities that creates cultures, processes, procedures, behaviors, technologies and environments in healthcare that consistently and sustainably lower risks, reduce the occurrence of avoidable hazards, make mistakes less likely and reduce their impact when they occur. The overall implementation of patient safety as many as 58.6% of respondents felt that it was good, where there was a significant relationship between the application of patient safety to the quality of drug services, pharmaceutical installation services, nutrition services, laboratory services and radiologist services (Dalfian et al., 2022).
Patients need to know about patient safety so that they have awareness about the rights that must be given to patients, especially about safety during hospitalization. The patient's perception of patient safey is related to efforts to save patients with services provided in accordance with SOPs or not. Efforts are made with respect for the rights of patients, the suitability of a series of tests carried out and also the absence of practice malls.
This study is in line with other studies that show patients have heard of patient safety. There are some patients who say that patient safety is an effort of readiness from hospital staff to keep unwanted things from happening such as negligence, emergency management, medical personnel who are attentive to their patients, medical personnel who take actions according to procedures and SOPs, maintain health, have a healthy lifestyle, commitment of hospital management in providing patient safety infrastructure (Kusumastuti et al., 2021).
The speed and responsiveness of health workers is part of the services directly handled by health workers, and is always there when there are patients who need care and services. In addition, the characteristics of health workers also do not escape the patient's answers about attitudes and behaviors in providing services and their ability to take action to patients.
Clear information given to patients is also one of the important things for patients. This is related to the flow of patients from coming to return and the hospital referral system. Communicating with patients needs to be enforced by health workers by listening and engaging patients. In addition, identified factors that hinder and facilitate participation are identified, such as patients wanting to take on passive roles, the lack of teamwork that participants understand will improve interprofessional understanding and improve patient safety (Oxelmark et al., 2018).
Patient safety is also related to clean, standardized and complete hospital infrastructure and facilities. Means that need to be considered are a clean room, a non-slippery floor, sterile medical devices. Meanwhile, good facilities with comfortable beds, sufficient waiting rooms, supporting equipment, fire extinguishers and disaster evacuation routes and sturdy buildings.
Improved safety in primary care is critical when striving to achieve universal health coverage and health care sustainability. Patient and staff involvement is another important factor that healthcare providers in both developing and developed countries should consider. Patients can help healthcare practitioners improve their practices, services, and decision-making processes by reflecting on their experiences (Kuriakose et al., 2020).
Based on the results of research, theory and previous research shows that patients' perceptions of patient safety are good. Some of the understanding of patients include, patient safety is illustrated from services that are in accordance with SOPs, fast and responsive services, professional services and also cleanliness of tools and rooms and completeness of facilities.

CONCLUSIONS AND SUGGESTIONS
From the results of the research and discussions carried out, the conclusion is that the implementation of patient safety during the COVID-19 pandemic has been carried out by adhering to six patient safety goals, namely identifying patients appropriately, communicating effectively, improving drug safety, ensuring the accuracy of surgical procedures, reducing the risk of health service-related infections, and reducing the risk of injury to patients due to falls. Management support is indispensable to improve patient safety, both in terms of optimizing the quality of service, regulatory policies and compliance with guidelines, as well as training on patient safety for new staff. However, there are financial constraints due to the decline in the number of patients and narrow rooms, so it is still not up to standard. In addition, officers are also less aware of the changing safety culture during the COVID-19 pandemic. Incident reporting commitments are also needed, as there is still a lack of incident reporting despite the provision of clear reporting forms and reporting flows. To improve patient safety, it is necessary to optimize the strategy plan by strengthening human resources, increasing the supply of consumables supplies, tightening policy regulations, regulating spatial planning, and improving the patient referral system. Patient perceptions of patient safety in hospitals also need to be considered, such as services that are in accordance with procedures, responsive, and competent, information about the flow of the hospital and a clear patient referral system, standardized cleanliness and room facilities, completeness of waiting room facilities, and availability of patient aids in the hospital. Based on the results of the study, discussion, and conclusions that have been drawn, the suggestion for the next study is to add variables and focus the research on strategies for implementing patient safety. Further research should also not only focus on one hospital, but also compare with other hospitals.