Bhayangkara Lumajang Hospital has a patient safety incident form. But on the form there are often items that are not filled, namely age group and type of incident. And at Bhayangkara Lumajang hospital there is an infection surveillance form. at infection surveillance form there are items that often not filled, namely move rooms. Furthermore, there are items that are not listed on the form on the infection surveillance form in the risk factor. At the Bhayangkara Lumajang hospital there is also work accident form. But on the work accident form there is no authentication. The purpose of this study is created patient safety incident form, infection surveillance form and wore accident form. The kind of study is qualitative. Data collection by interview, observation and Focus Group Discussion. The theory used in this study is Huffman (1999) which includes physical aspects, anatomical aspects and content aspects. The results of this study are form patient safety incidents, infection surveillance and workplace accidents. Based onÂ physical aspects of the form using 70 gram A4 paper, in portrait form, using black ink and white paper. Based on anatomical aspect, the form of the head of the form (heading) is located at the top, there is an instruction (instruction), using the arial 11 font and the method of fill the form is manually. Based the content aspect of the form the items are complete, there are groupings and items arranged in sequence and on the form, abbreviations and symbols used in accordance with the applicable standards in the hospital. The hospital should periodically evaluate forms related to phisical aspects, anatomical aspects, content aspects, items needed on the form and related item filllin out the form.
Keyword: Incident patient safety, Infection surveillance, Work accident