Healthcare Associated Infections (HAIs) merupakan peristiwa buruk yang paling sering terjadi dalam pelayanan kesehatan di seluruh dunia. Setiap tahunnya terdapat ratusan juta pasien terkena HAIs yang mengarah pada kematian secara signifikan dan menyebabkan kerugian finansial untuk sistem kesehatan. Di negara-negara berpenghasilan menengah dan rendah, frekuensi infeksi di ICU setidaknya 2-3 kali lebih tinggi daripada negara-negara berpenghasilan tinggi. Tujuan dari penelitian ini adalah mendapatkan hasil analisis tata laksana pencegahan dan pengendalian Health care-associated infections (HAIs) di unit perawatan intensif RSUD Koja menggunakan metode bow tie. Penelitian ini merupakan jenis penelitian operasional yang bersifat kualitatif. Metode yang digunakan adalah wawancara mendalam, telaah dokumen, dan observasi. Hasil penelitian ini menunjukkan bahwa penyebab angka HAIs di RSUD Koja masih diatas standar yakni adanya latent failure dalam upaya pencegahan dan pengendalian HAIs. Maka dari itu diperlukan perbaikan dalam beberapa variabel laten untuk memaksimalkan upaya pencegahan dan pengendalian HAIs, serta dibutuhkan penelitian yang membahas kondisi pasien sebagai ancaman dalam upaya pencegahan dan pengendalian HAIs di rumah sakit.

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Healthcare Associated Infections (HAIs) are the most frequent adverse events in health services throughout the world. Every year there are hundreds of millions of patients affected by HAIs that lead to death significantly and cause financial losses to the health system. In middle and low-income countries, the frequency of infections in ICUs is at least 2-3 times higher than in high-income countries. The purpose of this study was to obtain the results of analysis of prevention and control of Health care-associated infections (HAIs) in the intensive care unit at Koja Disrict Hospital using the bow tie method. This research is a type of operational research that is used qualitative method. The methods used are in-depth interviews, document studies, and observations. The results of this study indicate that the cause of the number of HAIs in Koja District Hospital is still above the standard, namely the presence of latent failure in efforts to prevent and control HAIs. Therefore, improvements in some latent variables are needed to improve the effectiveness of HAIs prevention and control efforts, and research is needed to discuss the patients condition as a threat in preventing and controlling HAIs in the hospital.