More than 1.3 million people are admitted to hospital annually in the Netherlands. In 2004 about 76,000 patients were confronted with unintentional health care-related harm, or ‘adverse events’. In approx. 30,000 cases damage was done to patients that could potentially have been avoided. In 2004 around 10,000 patients ended up with unintentional lasting damage during a hospital admission. This could have been prevented to some degree with 6,000 patients. Such adverse events cause additional suffering to patients, but also carry negative consequences for the carer or institution.

The aim of the research is to find out the nature and causes of adverse events and focuses on technical causes, organizational causes – including communication and culture – human causes and patient-related causes. A deeper understanding of the causes of adverse events can facilitate specific improvement initiatives.

The spearheads of the research are to validate methods of measuring patient safety and adverse events, the influence of the care facility on the occurrence of adverse events, the influence of inter-professional communication and cooperation on the occurrence of adverse events and the assessment of interventions to improve patient security. A guideline for the implementation of a safety management system has recently been developed for care for the elderly. In practice, it turns out that a key element – reporting, analyzing and learning from incidents – is still having difficulties getting off the ground. Reportings are in fact being registered, but only a limited analysis is carried out. Even more rarely are reports used to learn and improve. In the project ‘Leren van Incidenten in de Zorg’ [‘learning from care incidents’, LIZ] a web site has been developed (www.nivel.nl/liz, in Dutch only) which aims to support care facilities using an incident-based learning system. In many facilities, a change of culture is needed for this to work. Only in an open and pro-active safety environment can lessons be learnt from incidents optimally, and only in such an environment can resident and client safety be expected to improve. In the coming years the research will focus on assessing the safety environments in long-term geriatric care. Similar paths are being developed for the care for the mentally challenged and for mental health care. Research into the introduction of a new safety culture closely links in with the research into health care innovations, as described in in the research domain Care Professionals and Organisation.