Healthcare will never be a 100% safe. Patients are vulnerable and undergo diagnostic and therapeutic procedures which carry risks. Physicians and nurses make decisions which can turn out to be wrong.
In many organizations, when an adverse event occurs, the tendency is to find an individual to fix the blame on. Making a mistake in healthcare is often seen as an accountable failure of an individual; by the patient, the work environment as well as the individual who made the mistake. This leads to a culture in which mistakes and adverse events are preferably not addressed. A resultant is that the organization is not redesigned after a mistake or an adverse event and the outcome of care remains highly dependent upon human performance. Thus, extra pressure is put upon individuals not to fail and so the circle is complete.
The UMC Utrecht seeks a different approach to dealing with mistakes and adverse events. Just like other high-risk industries (e.g. aviation) and an ever growing amount of healthcare organizations, the UMC Utrecht considers human performance as a part of the system. It recognizes that human error is inevitable. Wherever possible, the system should be (re)designed in such a way that human error is discovered or intercepted before it leads to patient harm. Only when evidence is found of wilful misconduct or gross negligence, are actions against individuals justified.
This way the focus of attention shifts from fixing the blame to fixing the problem.