From Incident to Improvement: A Root Cause Analysis of Needle Stick Injuries in a Private Type-C Hospital in Indonesia
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Dinda Iryawati
Hadijah
Abstract
Introduction: Needle stick injuries (NSIs) remain one of the most persistent occupational hazards among healthcare workers (HCWs), posing significant risks of exposure to blood-borne pathogens. Despite continuous implementation of infection prevention and control (IPC) programs, NSIs continue to occur across healthcare settings, reflecting both behavioral and systemic vulnerabilities.
Objective: This study aimed to analyze the characteristics and underlying causes of NSIs using a Root Cause Analysis (RCA) approach in a private type-C hospital in Bogor, Indonesia.
Methods: A descriptive retrospective study was conducted using secondary data from the hospital’s incident reporting system between January 2022 and October 2025. Descriptive statistics were used to summarize NSI trends by year, professional category, and department. One representative NSI case was further examined using the Ishikawa 6M (Man, Method, Machine, Material, Measurement, and Milieu) framework to identify root causes and develop targeted corrective and preventive actions.
Results: Seventeen NSIs were reported during the study period. Nurses were the most affected group (58.8%), and inpatient wards were the most common locations (35.3%). RCA revealed contributing factors including excessive workload, limited awareness of safety protocols, inadequate preparation and equipment availability, use of non-safety needles, lack of compliance monitoring, and overcrowded work environments. The resulting action plan encompassed staff training, workload adjustments, equipment upgrades, workspace reorganization, and regular compliance audits.
Conclusions: NSIs in this setting were driven by both human and system-level factors. Addressing behavioral, procedural, and environmental weaknesses through integrated corrective and preventive measures is essential to strengthening IPC practices and fostering a culture of safety among HCWs.
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