Patient safety is an important issue in the health care sector. Because of this, three years ago University Medical Center (UMC) Utrecht started the Patient Safety Project. The project resulted in the establishment of the Patient Safety Center at the end of 2006. In addition to introducing safer procedures for patients and sharing knowledge about patient safety, the center also conducts research.

In 2004, UMC Utrecht staff members developed a way to systematically reconstruct and evaluate incidents. Known as Root Cause Analysis (RCA), this method of analyzing incidents quickly became popular throughout the Netherlands. Although the use of RCA has been met with enthusiasm, the positive effects of hospital-wide implementation have never been proven.

Does RCA work?

The Patient Safety Center set up a study to scientifically demonstrate the value of RCA. To do so, researcher Ian Leistikow divided the hospital in two. In one half of the hospital, staff members analyze incidents using the RCA methods, and in the other half they do not. “Since the introduction of RCA, we’ve seen a sharp rise in the number of incidents being reported in both groups. But it’s been hard to show what role RCA has played in this,” says Leistikow.

Shortcoming

Leistikow continues: “The big problem is that we can’t measure whether the number of incidents has dropped. We know there has been an increase in the number of reported incidents. However, I think this is more likely to be the result of a greater willingness to report incidents than of a rise in the number of incidents. What we also see is that there has been a drop in the number of complaints made by patients. In order to find out to what extent things are going wrong, we will set up a ‘Continuous Outcome Registration.’ This involves asking patients about their hospital experiences and their state of health after they are discharged. By doing this, we should be able to find out whether or not the patient has been affected by undesirable outcomes such as incidents or complications.

Patient handover in Intensive Care

Right now, the Patient Safety Center is coordinating a study on the handover of patients in Intensive Care. Researchers are making films of these handovers in a number of different hospitals. This allows them to see whether information is being lost during handover and what kind of information this is. Around 500 films have already been made. “We’re helping the doctors and nurses to develop a framework, so that less information is lost,” explains Liesbeth van Rensen. As senior researcher, she is overseeing the study. “Once the framework has been put in place we’ll film the handovers again – in this way we’ll be able to see whether there have been improvements.”