Rapport Patiëntveiligheid, de rol van de bestuurder - Veilige zorg ...

such as financial deficits, obtaining new technology, market share or labourshortages.AmbiguityThe second trait is the high level of ambiguity. The evidence for a clearcause-effect relationship is often inconclusive. An example can be seen inthe discussions about the role of systems versus the role of behavior. For along time bad outcomes were typically attributed to bad behavior. Researchon morbidity and mortality meetings showed that most adverse outcomeswere blamed on an individual professional. Since the publication of “To ErrIs Human” more and more people started to embrace the concept of systemfailure as the cause of adverse events. The problem, however, is that bothsides are right. Almost all adverse events in healthcare can be attributed toboth system errors and individual errors, depending on what side of thediscussion one stands. There is no “one right answer”. The high level ofambiguity leads to inconsistent research outcomes. Even though the amountof patient safety research has increased exponentially since the turn of thecentury, there is much debate about the quality of the studies and themethods used. This is fuel for critics and leads to time being spent ondiscussing the validity of the research instead of on improving the safety forpatients.DiversityThe third trait that impedes patient safety improvements is the high level ofdiversity. Practically everything that is done in healthcare can be related topatient safety. The variety in ways that unsafety can manifest itself is alsoinfinite, as is the variety in causes of unsafety. As a consequence, one canfeel overwhelmed by the sheer magnitude of the problem. In complex andtightly coupled organizations as hospitals, unsafety will always find a way toexpress itself. This realization can lead to fatalism, the idea that it is uselessto make one aspect of care safer, because then the unsafety will strikesomewhere else. It can also lead to heated discussions between professionalsand executives about which safety problem is the most urgent. Executivesmight think compliance to regulations (e.g. using a mandatory pre surgicaltime-out procedure) is paramount, while professionals want may want tofocus on proper equipment and staffing. Both can argue the importance oftheir issue and both can be right at the same time.382summary